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American Journal of Epidemiology Copyright ª 2006 by the Johns Hopkins Bloomberg School of Public Health All rights reserved;

printed in U.S.A.

Vol. 163, No. 10 DOI: 10.1093/aje/kwj119 Advance Access publication March 29, 2006

Original Contribution Psychosocial Work Environment and Incidence of Severe Depressive Symptoms: Prospective Findings from a 5-Year Follow-up of the Danish Work Environment Cohort Study

¨ ltmann, Birgit Aust, and Hermann Burr Reiner Rugulies, Ute Bu
From the National Institute of Occupational Health, Copenhagen, Denmark. Received for publication June 22, 2005; accepted for publication October 10, 2005.

The authors analyzed the impact of psychosocial work characteristics on the incidence of severe depressive symptoms among 4,133 (49% women) employees from a representative sample of the Danish workforce between 1995 and 2000. Psychosocial work characteristics at baseline included quantitative demands, influence at work, possibilities for development, social support from supervisors and coworkers, and job insecurity. Severe depressive symptoms were measured with the five-item Mental Health Inventory of the 36-item Short-Form Health Survey, with a cutoff point of 52. Women with low influence at work (relative risk (RR) ¼ 2.17, 95% confidence interval (CI): 1.23, 3.82) and low supervisor support (RR ¼ 2.03, 95% CI: 1.20, 3.43) were at increased risk for severe depressive symptoms after exclusion of cases at baseline and adjustment for sociodemographic factors, baseline depression score, and health behaviors. Further adjustments for socioeconomic position did not change the result substantially. Additional analyses showed that a one-standard deviation increase on the influence scale resulted in a 27% decreased risk of severe depressive symptoms. Among men, job insecurity predicted severe depressive symptoms (RR ¼ 2.04, 95% CI: 1.02, 4.07). The findings indicate that the work environment influences the risk of developing severe depressive symptoms and that different factors play a role for men and women. anxiety; depression; longitudinal studies; mental health; social support; stress, psychological; workplace

Abbreviations: CI, confidence interval; DWECS, Danish Work Environment Cohort Study; MHI-5, five-item Mental Health Inventory of the 36-item Short-Form Health Survey; RR, relative risk.

Editor’s note: An invited commentary on this article appears on page 888, and the author’s response appears on page 891.

Depression is a major burden of disease and includes such diagnoses as unipolar (major) depression, dysthymia, or depressive episodes, according to the fourth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (1) and the International Classification of Diseases, Tenth Revision (2). The World Health Organization reports

that the point prevalence for unipolar depression is 3.2 percent for women and 1.9 percent for men, with a 12-month prevalence of 9.5 percent for women and 5.8 percent for men (3). Unipolar depression is the fourth leading cause of ‘‘disability-adjusted life years’’ (3, 4) and the leading cause for ‘‘years of life lived with disability’’ in men and women in the world (3). Depression is not only adverse in itself but also triggers severe negative consequences. On the societal level, depression contributes to long-term sickness absence and early retirement (5, 6). On the individual level, depression might lead to life-threatening diseases. Two recent meta-analyses

´ 105, DK-2100 Copenhagen, Denmark Correspondence to Dr. Reiner Rugulies, National Institute of Occupational Health, Lersø Parkalle (e-mail: rer@ami.dk).

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Am J Epidemiol 2006;163:877–887

423 were employed at the time of the survey and therefore eligible for the study.80 3 0.83 ¼ 66 percent). a random sample of 9.308 British civil servants. respectively.552 employees of an electricity and gas company. In 1990. with higher values indicating higher influence and higher possibilities for development. Quantitative demands. A more detailed description of DWECS has been published elsewhere (15). including the application of standardized scales on psychosocial work characteristics.’’ ‘‘never. control. All six factors are well recognized as important psychosocial exposures at work and have been used in several other studies (9. In 1995. 24–28). as well as a high effortreward imbalance (14). participants were asked if they receive ‘‘support and encouragement’’ from their supervisors and from their coworkers. The scales were built by summing up the numerical values of the response options. The MHI-5 consists of five items on the frequency of depressive symptoms in the past 4 weeks. The items and response categories of the psychosocial work characteristics are provided in the Appendix. estimated combined response rate: 0. social support from supervisors. In 1995 and 2000. Therefore. to our knowledge. Measurement of psychosocial work characteristics The analyses are based on data from the Danish Work Environment Cohort Study (DWECS). in a French cohort with 11. the same people were contacted again. most of these studies are cross-sectional in design and therefore do not allow causal inference. Among the respondents.653 Danish residents was drawn from the Central Population Register of Denmark and interviewed by phone on various aspects of work and health. (13) found. high psychological demands. Job insecurity was measured with four dichotomous (yes/ no) items asking the participants if they were worried about Am J Epidemiol 2006. influence at work. predicted the incidence of minor psychiatric disorders (which were identified as mainly depressive symptoms) in men and women.470 (response rate: 83 percent. Numerous studies have investigated whether psychosocial work characteristics are associated with a higher probability of major depression and depressive symptoms. and 942 did not respond to the follow-up questionnaire. for an overview. yielding a scale with scores ranging from 0 to 100. We asked participants if the amount of their work is so extensive that they do not have time to think and talk about anything else than work. found that depression was an independent risk factor for myocardial infarction and death due to coronary heart disease in initially healthy people (7. Respondents scoring below the median on the two scales were categorized as exposed to low influence and low possibilities for development. For the purpose of the analyses in this paper. no prospective study has yet been conducted that investigated this association in the general working population. In accordance with studies from others (20. refer to the article by Tennant entitled. Niedhammer et al. and low social support at work (10.583 participated in the survey (response rate: 80 percent).878 Rugulies et al. at the time of the baseline assessment. 12. that demands. and therefore the items and the scales for this study were constructed by a research group at the National Institute of Occupational Health in Denmark (15). we classified participants scoring 52 points or less as cases of severe depressive symptoms. with higher scores indicating fewer depressive symptoms. and new participants additionally supplemented the cohort. 10. Only a few studies have utilized prospective data so far. Depressive symptoms were measured in 1995 and 2000 but not in the 1990 survey. Using components of the ‘‘demand-control-support model. Scores were summed up and standardized. Measurement of severe depressive symptoms Severe depressive symptoms at baseline and at follow-up were assessed with the Danish version of the five-item Mental Health Inventory (MHI-5) of the 36-item Short-Form Health Survey (16–19).’’ that is. A complete list of the items is provided in the Appendix. Regarding social support. 20–22). social support from supervisors. respectively. analyses in this paper are based on baseline variables in 1995 and the incidence of severe depressive symptoms in 2000. Of these. Although the scale is meant to measure mental health in general. Participants who answered that this is true for at least half of the working hours were categorized as having high quantitative demands. low decision authority. possibilities for development. ‘‘Workrelated Stress and Depressive Disorders’’ (9). Of these. resulting in a final study sample of 4. yielding a follow-up sample of 4.133 participants (figure 1).’’ or ‘‘I do not have a supervisor’’/‘‘I do not have coworkers’’ were categorized as exposed to low supervisor support and low coworker support. 13. 23). MATERIALS AND METHODS Study sample the variables of interest and 104 participants who had shown severe depressive symptoms in 1995. Although these and other studies with selected occupational groups provide insight into the association between the psychosocial work environment and depression. social support from coworkers. Respondents who answered ‘‘usually not. Influence at work and possibilities for development were measured with scales consisting of three items each. and social support from coworkers were measured with single items.163:877–887 . 8). Stansfeld et al. in a 5-year follow-up with 10. This paper aims to fill this void by analyzing the impact of psychosocial work characteristics on the incidence of severe depressive symptoms in a 5-year prospective study with a representative sample of the Danish workforce. 11 emigrated or died during the follow-up period. respectively. However. a review of the literature showed that the instrument seems to be most appropriate for measuring severe depressive symptoms (16. (12) found that these components predicted the onset of depression over a 12-month follow-up. 5.702 Danish residents were approached to participate in DWECS. we further excluded 233 participants with missing values on We measured six psychosocial work characteristics: quantitative demands. and support. 11). no reliable Danish instrument measuring these factors existed. and job insecurity. However. 8.

31 (p < 0.5 percent of the 4. We combined cohabitation and children living at home into the variable ‘‘family status. or one shot of liquor. statistical program package (Stata Corporation. Measurement of covariates We recorded the covariates age. cohabitation. that is. With four response categories corresponding to sedentary. with 84 percent of the participants scoring 80 points or more. and 4) having difficulty in finding another job if they became unemployed. leisure-time physical activity was assessed with the question.0. gender. Depression scores in 1995 and in 2000 were positively correlated with a correlation coefficient of 0. among the 3. family status.53 and 0.06 with a standard deviation of 12. smoking.160 nonemployees in 1995. health behaviors. Model 2 was additionally adjusted for health behaviors.78 in 1995 and 0. Slightly more than one fourth had an advanced school education. 3) single with child. version 7.’’ Alcohol consumption was categorized by three groups: 1) no consumption of alcohol. for women and men. alcohol consumption. including commuting to or from work. respectively. II (middle managers and/ or having more than 3–4 years of further education).1 percent in 2000 were found among the 2. College Am J Epidemiol 2006.. 2) had changed workplaces during this period. with ‘‘heavy consumption’’ defined as drinking more than two and three units per day. The mean age of the sample was 39 years with a standard deviation of 11 years. The highest level of school education was categorized in accordance with the Danish educational system. This reduction was caused mainly by excluding persons who were not employees in 1995. we repeated model 2 for a study sample of 4.7 for men). RESULTS All analyses were conducted with the STATA. and strenuous physical activity. There were 105 participants (68 women and 37 men) with severe depressive symptoms at follow-up.001). and leisure-time physical activity. Cronbach’s alpha for the depression scales was 0.33 liter). we used the two scales on influence at work and possibilities for development as continuous variables to assess the relative risk for severe depressive symptoms for each one-standard deviation change of the scales. to what group do you belong?’’ Socioeconomic position was defined by employment grade. Using the six categorical psychosocial workplace characteristics as predictors and the incidence of severe depressive symptoms as the outcome.4 percent in 1995 and 7. and the majority worked as white collar workers (table 1). Correlations between depression scores at baseline and follow-up were calculated with Pearson’s correlation coefficients. because other studies have found them to be related with psychosocial work characteristics. . 2) being transferred to another job against their will. 3) becoming redundant as a result of new technology. alcohol consumption. and education. or 3) was no longer employed at follow-up.64.237 participants that also included the 104 persons with severe depressive symptoms at baseline.37. and socioeconomic position.583 responders to the 1995 baseline survey but only among 2. Whereas smoking was assessed in the 1995 baseline survey.e. and 3) earned advanced education. and V (semi. one glass of wine.7 percent in 2000.348 persons who were out of the labor market (not shown in the figure). IV (skilled blue collar workers).81 in 2000.or unskilled blue collar workers). The mean score on the depression scale at follow-up was 87. and 4) single without child. mental health. Statistical analysis Station.4 for women and 1. Internal consistency of the depression scale and the work environment scales was estimated with Cronbach’s alpha.9 percent of the 8. number of children living at home.5 (3. For example. Texas). The highest prevalence rates with 10. alcohol consumption and leisure-time physical activity had to be derived from the 2000 follow-up survey.1 percent in 1995 and 5. respectively. we calculated gender-stratified relative risks and 95 percent confidence intervals with multivariate logistic regression models. moderate. yielding five categories: I (executives and/or academics). A ‘‘unit’’ was defined as one small bottle of beer (0. caseness of severe depressive symptoms was 8. job title. in the direction of fewer depressive symptoms). In addition. Caseness of severe depressive symptoms in 2000 was found among 3. In an additional analysis. Respondents who answered ‘‘yes’’ to at least one of the four items were categorized as exposed to job insecurity. yielding an incidence rate of 2. and 3) heavy consumption. school education. III (other white collar workers). Model 3 was further adjusted for socioeconomic position. 2) cohabiting without child. change in employment status. We included these variables. and depression score at baseline. Covariates were included in three different models. yielding three groups: 1) left school without completing the 10-year examination.133 persons in the final study sample. The percentages of cases decreased throughout the exclusion process. and leisure-time physical activity. light. Cronbach’s alpha values for the influence at work and the possibilities for development scales were 0. Smoking was dichotomized as current ‘‘smokers’’ and ‘‘nonsmokers. The score was not normally distributed but heavily skewed to the right (i. change in employment status. Health behaviors included smoking. 2) moderate consumption. or both (29–35). The variable ‘‘change in employment status’’ indicated if a respondent had experienced any of the following circumstances: 1) had been at the same workplace between baseline and the follow-up survey. highest level of school education.Psychosocial Work Environment and Depressive Symptoms 879 any of the following situations: 1) becoming unemployed. Model 1 was adjusted for age. ‘‘When you should describe your leisure-time physical activity in the last year.’’ with the following categories: 1) cohabiting with child. 2) completed the 10-year examination.163:877–887 Figure 1 gives an illustration of the exclusion process and shows the percentage of participants with severe depressive symptoms in 1995 and 2000 at each step.

26).10.96. possibilities for development. 3.163:877–887 .43) were predictive for the onset of severe depressive symptoms. social support from coworkers. 95 percent CI: 1. Low influence at work (relative risk (RR) ¼ 2. There were no effects for quantitative demands. for low supervisor support: RR ¼ 1. health behaviors. When socioeconomic position was added (model 3).82) and low social support from supervisors (RR ¼ 2. when adjusted for sociodemographic factors. and job insecurity.20.03.17. we a found a dose-response relation between increasing Am J Epidemiol 2006.13. 95 percent CI: 1. 95 percent CI: 1. Illustration of the exclusion process in the determination of the final study sample and the percentage of participants with severe depressive symptoms in 1995 and 2000 at each step. 3. and depression score at baseline (model 2). Table 2 shows the relative risks for severe depressive symptoms for psychosocial work characteristics among women. 3. Danish Work Environment Cohort Study (DWECS). 3.92. 95 percent confidence interval (CI): 1. FIGURE 1.880 Rugulies et al.23.47. When we analyzed influence at work and possibilities for development as continuous variables (data not shown in table). effect estimates decreased somewhat more but remained substantial (for low influence: RR ¼ 1.

91. Among men.45). the association between psychosocial work characteristics and severe depressive symptoms was remarkably different. No statistically significant associations were found for quantitative demands.548 482 875 13. possibilities for development. For possibilities for development.1 37. Sociodemographic characteristics of the 4.or unskilled blue collar workers Incidence of severe depressive symptoms at follow-up in 2000 Yes No 105 4. 28). Influence at work and possibilities for development as continuous variables were also unrelated to the risk of severe depressive symptoms (data not shown in table). Executives/academics II. on the other hand. and the use of the representative sample allows generalizing the findings for the Danish workforce.06).29 to 1.171 1.0 1. % Gender Women Men Age (years) <35 35–44 45–54 55 Family status Cohabiting with child Cohabiting without child Single with child Single without child School education Left school without completing 10-year examination Completed 10-year examination Advanced education Socioeconomic position I.20).5 51.30) and among men for supervisor support (from 1.5 Repeating the analyses of model 2 for a study sample also including persons with severe depressive symptoms at baseline did not change the effect estimates substantially for most variables. we excluded persons with severe depressive symptoms at baseline and also adjusted for baseline . DISCUSSION influence at work and decreasing risk of developing severe depressive symptoms.006).7 1.17 to 1. and psychological distress (12. model 3: RR ¼ 2. p ¼ 0. p ¼ 0.7 21. 1.4 2.Psychosocial Work Environment and Depressive Symptoms 881 TABLE 1. 13. Semi.1 26. Moreover. These results are in line with other prospective studies that found low control at work and low social support predictive for depression.73.8 30. 4. no statistically significant effect was found.5 97.004 390 37.4 11.01. influence at work.63. However. 4.5 564 664 1.247 178 732 47.6 16.3 9.07.9 28. Whether these gender differences may be partly explained by differences in the structure of the occupations and thus different work characteristics for men and women (37) or by differences in the perception of or vulnerability to work conditions (38) or whether they emerge because of a different time course of psychosocial work characteristics in the onset of depressive symptoms cannot yet be determined.2 4. Changes of relative risks of 10 percent or more were observed among women for influence at work (from 2. a one-standard deviation increase on the influence at work scale resulted in a 27 percent decreased risk of severe depressive symptoms (RR ¼ 0.576 1. 95 percent CI: 1. Among women.17 to 2. Middle managers/white collar workers with further education III. Job insecurity. whereas in our study the effect of job insecurity was restricted to men.3 24. 0. Additional adjustment for socioeconomic position resulted in a relative risk of 0.59.02.04.074 35. was predictive. 95 percent CI: 1.976 1. Strengths of the study To our knowledge.9 38. low influence at work showed a dose-response relation with risk of severe depressive symptoms. The different patterns of association between psychosocial work characteristics and severe depressive symptoms for men and women in our study underline the importance of conducting gender-stratified analyses when studying depression. and social support from supervisors and from coworkers. (36) that job insecurity is a risk factor for minor psychiatric disorders and depression. Other white collar workers IV.11 to 1. Skilled blue collar workers V.483 1. Neither influence at work nor social support from supervisors was associated with severe depressive symptoms.004 2. 95 percent CI: 0.163:877–887 Psychosocial work characteristics were prospectively associated with the development of severe depressive symptoms in this representative sample of the Danish workforce. psychiatric disorders. low influence at work and low social support from supervisors resulted in a twofold increased risk.04. this is the first time that prospective analyses on the impact of psychosocial work characteristics on severe depressive symptoms were conducted in a representative sample of the general working population. Table 3 shows the relative risks of severe depressive symptoms for psychosocial work characteristics among men. these gender differences merit further exploration.09.129 48.80 (95 percent CI: 0. After adjustment for the covariates from model 2. Ferrie et al. found job insecurity to be predictive in both men and women.3 17. Job insecurity was predictive in all three models (model 2: RR ¼ 2.568 1. which is in line with findings from Ferrie et al.41 when cases at baseline were included) and possibilities for development (from 1.028 2.46) and coworker support (from 1. Am J Epidemiol 2006.133 Danish Work Environment Cohort Study participants in 1995 and the incidence rate of severe depressive symptoms in 2000 No.2 1. In the analyses. The prospective nature of the study allows causal inference. Certainly.

3.80 0.92 1.00 1.00 1.20.90 4.36 1.42 3.004 employed women.66. was developed to measure mental health and has been used as a measurement of both mental health in general and depression.14 0.803 201 59 9 3. alcohol consumption (at follow-up).11 0.23 1. 1.23 1. Am J Epidemiol 2006.47 1.46 1. depression score to reduce the possibility that depressive symptoms affected the perception of psychosocial work characteristics.50 947 1.96 1. A priori.44 1.00 1.49.27 4. 3.00 1. After a review of the literature.00 1. family status (cohabiting and having children).00 2.46. which then increases the risk of disease (39–42). but with a questionnaire.65. (16) compared the MHI-5 with several other diagnostic instruments.43 1. and socioeconomic position (model 3).057 18 50 1. Rumpf et al.48 1. socioeconomic position was based mainly on occupational status. and substance use disorders had considerably lower receiver operating characteristics curves of 0.65. 0.82 1.07 0.88. 3. 1.00 2.62. 2.46.) Quantitative demands Low§ High Influence at work High§ Low Possibilities for development High§ Low Social support from supervisor High§ Low Social support from coworkers High§ Low Job insecurity No§ Yes 1.00 1.21 0.043 28 40 2.611 393 43 25 2. 1.05 1.00 0. 1.26 961 1.71.402 602 48 20 3. We find this argument convincing and therefore believe that the analysis in model 2 is the most appropriate. y Model 2 was adjusted for all the variables in model 1 plus smoking (at baseline).99 1. including family status. and 0.00 0.73.86 0.00 2. 3. and leisure-time physical activity (at follow-up).83 0.03 1.97 0.87 1.55. Strand et al. % Relative risk Model 1* 95% confidence interval Relative risk Model 2y 95% confidence interval Relative risk Model 3z 95% confidence interval Psychosocial work characteristics Exposed (no.92 1.22. TABLE 2.00 1. 1.73.13. and depression score at baseline (continuous). 3.84 1. school education. We further adjusted for other potential confounders.51.48.10. 1.17 1.98 0.70 * Model 1 was adjusted for age (continuous).00 0.05 0.00 0. (21) validated the MHI-5 against clinical diagnoses with a diagnostic interview and found that the sensitivity and specificity of the MHI-5 were most satisfactory for mood disorders (which includes major depression and dysthymia).73 1. we concluded that the MHI-5 is an acceptable instrument to measure severe depressive symptoms. This questionnaire.00 1.11 1. Consequently. 44). with an area under the receiver operating characteristics curve of 0.00 1. Limitations of the study A limitation of this study is that severe depressive symptoms were not assessed with the ‘‘gold standard. As shown in Materials and Methods.00 0. the MHI-5.99 1. However.21 0.68. z Model 3 was adjusted for all the variables in model 2 plus socioeconomic position.91 3. (20) and Berwick et al. 1. 1995–2000 Incident severe depressive symptoms No.129 875 33 35 2.32 1. § Referent. 2. 1.27.91 1.00 2. and both concluded that the MHI-5 is a valid instrument to measure depressive disorders.04 0. somatoform disorders. health behaviors (model 2).23. 2. Danish National Work Environment Cohort Study. researchers in the field of work and health have pointed out that controlling for occupational status when analyzing associations between psychosocial work characteristics and health outcomes could cause overadjustment (43. we also showed the findings for model 3 in order to address recent criticism that associations between psychosocial work characteristics and health outcomes are confounded by more favorable psychosocial exposure patterns among people of higher socioeconomic position (45–47). respectively. 3. 1. Anxiety disorders.67 6. we viewed model 2 as the most appropriate model.25 1.39 1.163:877–887 .’’ a diagnostic interview.50.74 1.00 1.92 4.882 Rugulies et al. change in employment status during follow-up. Impact of psychosocial work characteristics on the incidence of severe depressive symptoms in 2. It has been argued that low occupational status increases the likelihood of exposure to adverse psychosocial work characteristics.

y Model 2 was adjusted for all the variables in model 1 plus smoking (at baseline).02.32 1. 2.76 1.00 0.60 0.57.00 0.30.25 * Model 1 was adjusted for age (continuous).61 0.20 1. within the follow-up period.59.19 1.’’ We examined the relation between psychosocial work characteristics and the onset of severe depressive symptoms by use of a 5-year follow-up period.16 0.20 0.18 0.58.46 0.Psychosocial Work Environment and Depressive Symptoms 883 TABLE 3.48 0. Impact of psychosocial work characteristics on the incidence of severe depressive symptoms in 2.00 1. It should be taken into account that.136 993 15 22 1.00 1.20 1. we did not use the terms ‘‘clinical depression.90 1. we are confident that the MHI-5 is an acceptable instrument to identify persons with severe depressive symptoms. alcohol consumption (at follow-up).60. Consequently. 4.33 0. which might have been statistically significant if the numbers of cases would have been higher. increasing the probability of a type II error (i.29 0.07 1. § Referent.23 1. forms of depressive disorders. Although it is reasonable to assume that a certain .129 employed men.00 1.803 326 27 10 1.519 610 22 15 1.00 0. 1.02. 2. This would be a nondifferential misclassification in the measurement of the exposure variable.26 0. albeit important. 2.59.00 0. 4.24 1.07 1. With regard to the exposure measures.30.29.04 1.00 0. it is possible that some participants developed severe depressive symptoms after the 1995 baseline survey but were no longer cases when we conducted the follow-up survey in 2000. people out of the labor market were at higher risk for severe depressive symptoms. Consequently.45 2.71 1.19.17 0.19 1.00 1.00 2. which would result in a potential underestimation of the effect sizes.77 1.46 1.48. and depression score at baseline (continuous). z Model 3 was adjusted for all the variables in model 2 plus socioeconomic position. % Relative risk Model 1* 95% confidence interval Relative risk Model 2y 95% confidence interval Relative risk Model 3z 95% confidence interval Psychosocial work characteristics Exposed (no. 2. However. Furthermore.60 0.074 1.58. Similar to most research on working conditions and health.09 1. for some participants. school education..26 0.00 1. family status (cohabiting and having children). Danish National Work Environment Cohort Study.84 1.331 798 15 22 1. 1995–2000 Incident severe depressive symptoms No.00 2.04. 2. 1. 1. our study is prone to selection bias because of the healthy worker effect (48).) Quantitative demands Low§ High Influence at work High§ Low Possibilities for development High§ Low Social support from supervisor High§ Low Social support from coworkers High§ Low Job insecurity No§ Yes 1.15 0. On the basis of these findings. As shown in figure 1.18. 2.06 1. high quantitative demands among men showed a relative risk of 0.32 2. 4.57.47 0.04 1.e. some of the confidence intervals were wide. change in employment status during follow-up. 2.00 1.00 1. changes may have occurred in both exposure and outcome variables.13 2. 1.22 1.163:877–887 phases of the follow-up period. the literature on the MHI-5 does not provide cutoff points for identifying mild and moderate depressive symptoms.92 1.628 501 31 6 1. 1. It has further to be noted that we had a relatively low number of incident cases.67 1.40 1. 1.’’ ‘‘unipolar depression.22 1. indicating an unexpected protective effect.61. it has to be noted that the MHI-5 scale covers exclusively affective symptoms and mood but not disturbance in daily function.00 2. For example.57. we might have failed to detect an effect for some exposure variables because of lack of statistical power). this would mean that.00 1.00 0. which is an important criterion in assessing depression in psychiatric interviews. especially among men. psychosocial work characteristics measured at baseline would differ from the exposure during some Am J Epidemiol 2006.39 1.82 1.00 1.055 19 18 1. 2.37 1.35 1.50 3.’’ or ‘‘major depression’’ for caseness in our study but used the more general term ‘‘severe depressive symptoms.18. and leisure-time physical activity (at follow-up). and we therefore did not conduct analyses of these less severe. 2. With regard to the outcome variable.

1:9–26. Am J Epidemiol 2006. Mental health: new understanding. Lakka TA. In this study. J Psychosom Res 2001.who. We were aware of this possible bias. The world health report 2001. Henderson M. text revision. Healthy work: stress. J Epidemiol Community Health 2005. (http://www. Chandola T.58:1483–99. we believed it would be more important to address the potential confounding effects of these two important health-related behaviors and therefore included them in the analyses. World Health Organization. World Health Organization.who. et al. (http://www.56:302–7. Goldberg M. 11. By including these variables in the analyses. because alcohol consumption and leisure-time physical activity measured in 2000 might have been influenced by the development of severe depressive symptoms during followup.int/ classifications/icd/en/). Arlington. Tennant C. sensorial. Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review. Reviews indicate that intervention strategies to improve the psychosocial work environment are available and effective (58–60).59: 70–4. Soc Sci Med 2004. Glozier N. (http://www3. 4th ed. however. Theorell T. 14. methods and data sources. The global burden of disease 2000 project: aims. Kristensen TS. This means that statistical associations between exposure and outcome might be the result of poor health’s causing a more negative view of the work environment or of a general negative response style that includes the self-assessment of both work environment and health. our study is limited with regard to the inclusiveness of the constructs we used to measure the psychosocial work environment. new hope. 56) and a distinction between intensive (high work pace) and extensive (long working hours) quantitative demands (57). Current issues relating to psychological job strain and cardiovascular disease research. cognitive. 1990. Murray CJL. productivity. There is also an ongoing debate on the need for an expansion of the psychological demands concept. Karasek R.29: 270–9. burden. Bjorner JB. Karasek R.cfm?path¼whosis. 54). and emotional demands (55. Lopez AD. 2. by adjusting for baseline depression scores in the analyses. Hence. Depression and early retirement: prospective population based study in middle aged men. New York. 7. we controlled for this bias. et al. 2005 update. 4. we might have biased the results toward the null hypothesis. Shipley MJ. Most of these new developments and discussions emerged after the 1995 survey of DWECS. Kauhanen J. Rugulies R. Leclerc A. 52). Work characteristics predict psychiatric disorder: prospective results from the Whitehall II study. et al. 5.163:877–887 Conclusion We conclude that psychosocial work characteristics contribute to the development of severe depressive symptoms in the Danish workforce. When new follow-up data on depressive symptoms are available from the DWECS 2005 survey. 6. 50). Fortunately. Karpansalo M. and the reconstruction of working life. Psychosocial factors at work and subsequent depressive symptoms in the Gazel cohort. improving the psychosocial work environment might be an important tool for reducing severe depressive symptoms. Starke D. REFERENCES 1. Switzerland: World Health Organization. 51. It has further been argued that concepts such as ‘‘meaning of work’’ and ‘‘predictability of work’’ can contribute to a better understanding of the psychosocial work environment (53. recent research indicates that a more comprehensive assessment of the psychosocial work environment is needed. Studies analyzing the associations between self-reported exposure to psychosocial work characteristics and selfreported measures of health are generally prone to what has been called ‘‘bias due to common method’’ or ‘‘triviality trap’’ (24.51:697–704. Psychosom Med 2003. Different aspects of the psychosocial work environment seem to be important for men and . International classification of diseases. (Paper 36). J Occup Health Psychol 1996. Diagnostic and statistical manual of mental health disorders: DSM-IV-TR. Occup Environ Med 1999. alcohol consumption and leisure-time physical activity. including mental health disorders (14.884 Rugulies et al.24:197–205. Niedhammer I. 9. Am J Prev Med 2002.330:802–3. 12. 10. were not measured at baseline but at follow-up only. 2002. proportion of these cases were not participating in the workforce because of depression. BMJ 2005.23: 51–61.burden_gbd2000&language¼english). Geneva. Although we used well-established constructs. Tenth Revision. Stansfeld SA. 15. Trends in the Danish work environment in 1990–2000 and their associations with labor-force changes. Geneva. 3. 49. Work-related stress and depressive disorders. including a differentiation in quantitative. Two covariates. 8. Theorell T. et al. et al. however. A review and meta-analysis. we will be able to conduct analyses with a more comprehensive assessment of the psychosocial work environment. we were able to address several of these issues in the 2000 survey by including substantially expanded and revised psychosocial work environment measurements (15). Holland Elliott K.cfm). 2005. ACKNOWLEDGMENTS Conflict of interest: none declared. NY: Basic Books. Wulsin LR. women. Long term sickness absence. Fuhrer R. American Psychiatric Association. 13.psych.int/whosis/menu.org/research/dor/dsm/index. Mathers CD. Switzerland: World Health Organization. VA: American Psychiatric Association. Depression as a predictor for coronary heart disease.65:201–10. The measurement of effort-reward imbalance at work: European comparisons. Switzerland: World Health Organization. 2001. Geneva. 2000. Burr H. Singal BM. There is accumulating evidence that the imbalance between high efforts and low reward at work increases the risk of ill health. Scand J Work Environ Health 1998. another proportion of these cases might have developed depression and left the workforce because of previous exposure to adverse psychosocial work characteristics. Siegrist J. Scand J Work Environ Health 2003. Finally. et al.

Bech P. Borg V. New York.163:877–887 36. Landsbergis PA. 31. London.40:153–64. 23. Feeney A. Murphy JM. 41. et al. psychiatric. Lorant V. Bosma H. et al. ed. et al. United Kingdom: Sage Publishers. Psychosom Med 1998. Kasl SV. 46. Albertsen K. J Occup Health Psychol 1998. Murphy LR. Watt T. A socio-psycho-physiological perspective. Marmot MG. Med Care 1998. Sherbourne CD. 33. Reported nonreciprocity of social exchange and depressive symptoms.57:565–70. Steptoe A. Explaining social class differences in depression and well-being.56: 450–4. social support. NY: Wiley.29: 169–76. Research methods in occupational epidemiology. 42. Grosch JW. 52. 43. et al. eds. and psychological disorders. 38.3:390–401. Goldman PA. 1989. Psychol Med 2002. Are the effects of psychosocial exposures attributable to confounding? Evidence from a prospective observational study on psychological stress and mortality. Performance of a five-item mental health screening test. 35. et al. Roxburgh S. SCL-5.109:96–103. Damsgaard MT. scaling assumptions. Job stress and cardiovascular disease: a theoretic critical review. Meyer C. Haarasilta LM. Work environment and smoking cessation over a five-year period. Deliege D. The social pattern of health and illness. J Clin Epidemiol 1998.37:265–77. Siegrist J. et al. Holmes WC. physiological measures. Dalgard OS. Kristensen TS. 24. and health related behaviours in British civil servants: the Whitehall II study. Johnston M. New York. case-finding measure for HIV seropositive outpatients: performance characteristics of the 5-item mental health subscale of the SF-20 in a male. et al.Psychosocial Work Environment and Depressive Symptoms 885 16. Psychiatry Res 2001. Stansfeld SA. Bjorner JB.32:164–71. Davey Smith G. 20. Kant IJ. Kristensen TS. Hapke U. 45. Shipley MJ. Measuring job stressors and strains: where we have been.17:120–7. Baum A. SCL-10. 44. Eaton W. Ferrie JE. Head J. Syme SL. London. Backmand H. I. Steenland K.32:333–45. Marmot MG. and personal health behaviors in young men and women. et al. Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. In: Kasl SV. Int J Sports Med 2003. et al.14:280–5.30:85–128. Strand BH. gender. 27.30:473–83. Cooper CL. J Occup Health Psychol 1996. 1996:42–67. Stansfeld SA. et al. Wilkinson RG. Is job strain a major source of cardiovascular disease risk? Scand J Work Environ Health 2004. 37.55:878–84. et al. United Kingdom: Routledge. 2004: 27–68. Bu ¨ ltmann U. BMJ 2002. et al. Correlates of depression in a representative nationwide sample of adolescents (15–19 years) and young adults (20–24 years). 48. Wilkenson R.1: 246–60. Research findings linking workplace factors to CVD outcomes. 157:98–112. Kaprio JA. A short. BMJ 2001. Syme SL. Med Care 1992. Stamford. Psychosocial work characteristics as risk factors for the onset of fatigue and psychological distress: prospective results from the Maastricht Cohort Study. et al. Hannerz H.33:1–9. Influence of physical activity on depression and anxiety of former elite athletes. 15:7–68. 51. Psychosocial work environment and sickness absence among British civil servants: the Whitehall II study. NY: Oxford University Press. 17.57:113–18. Allgo ¨ wer A.51:1001–11. Extending the model of effort-reward imbalance beyond work. and MHI-5 (SF-36). Screening for mental health: validity of the MHI-5 using DSM-IV axis I psychiatric disorders as gold standard. 25. Health and social organization: towards a health policy in the twenty-first century. North FM. Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men. 1987:307–18.324:1247–51. J Clin Epidemiol 1998. von dem Knesebeck O. Epidemiol Rev 1995. Bjorner JB. 47. 1998: 795–810. Work conditions as explanations for the relation between socioeconomic status. Checkoway H. Joksimovic L. Tambs K. Thunedborg K. Kujala U. Hemingway H.105: 243–53.36:237–43. 29. 28. Belkic KL.24:609–19. et al. CT: Appelton & Lange. Gender differences in work and well-being: effects of exposure and vulnerability. 39. 22. J Epidemiol Community Health 2002. where we are. Hurrell JJ Jr. eds. Heslop P. J Epidemiol Community Health 2001. Larisch M.55:209–14. Health Psychol 2001. Effects of chronic job insecurity and change in job security on self reported health. Stansfeld SA. et al. eds. Brunner E. Am J Epidemiol 2006. In: Wallace RB. Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehall II study. Social determinants of disease. Crawford-Brown DJ. 32. Psychosocial factors and public health: a suitable case for treatment? J Epidemiol Community Health 2003. Kasl SV. Eur J Public Health 2004. Kaprio J. 50. and reliability of the Danish SF-36. Measuring the mental health status of the Norwegian population: a comparison of the instruments SCL-25. Rugulies R.86: 332–40. Davey Smith G. Ware JE. 40. Am J Epidemiol 2003. Pearce N. et al. Davey Smith G. Aust B. The Danish SF-36 Health Survey: translation and preliminary validity studies.20:223–7.60:247–55. Marttunen MJ. The epidemiology of health and illness.51:991–9. Prevalence of major depression and stress indicators in the Danish general population. In: Sutton S. Syme SL. Olsen LR. J Occup Health Psychol 1998. Measuring job stressors and studying the health impact of the work environment: an epidemiologic commentary. Scand J Public Health 2004. J Psychosom Res 2003. Med Care 1991. Stress and health: issues in research methodology.322:1233–6. Nord J Psychiatry 2003. Soc Psychiatry Psychiatr Epidemiol 1998. 18. In: Blane D. Marmot M. Rumpf HJ. J Health Soc Behav 1996. et al. Am J Public Health 1996. present dilemmas. Macleod J. Depressive symptoms. Wardle J. Tests of data quality. Mortensen EL. seropositive sample. Simmons BL. 19. Socioeconomic inequalities in depression: a meta-analysis. Occupational differences in depression and global health: results from a national sample of US workers. Macleod J. Berufliche Gratifikationskrisen und depressive Symptome: Eine Querschnittsstudie bei Erwerbsta ¨ tigen im mittleren .3:368–89. Berwick DM. J Occup Environ Med 1998. minor psychiatric morbidity. Maxcy-Rosenau-Last public health & preventive medicine. Methodologies in stress and health: past difficulties. 34. Conceptual framework and item selection. Heslop P. 49. 30. future directions. von dem Knesebeck O. Macleod J. Acta Psychiatr Scand 2004. The MOS 36-Item Short-Form Health Survey (SF-36). 21. 26. Occup Med 2000. Van den Brandt PA. Nelson DL. and where we need to go. Belkic K. et al. Lennon MC. Fine L. Schnall PL. Balfour JL. The Sage handbook of health psychology.

et al. 2 ¼ to some extent. Socioeconomic status and psychosocial work environment: results from a Danish national study.886 Rugulies et al. The incorporation of different demand concepts in the job demand-control model: effects on health care professionals. 6 ¼ never). 4 ¼ 1⁄4 of working hours. 2 ¼ 3⁄4 of working hours. 4 ¼ no. Kristensen TS. Nielsen ML. 2 ¼ 3⁄4 of working hours. or 5 were coded as having low supervisor support. Do you receive support and encouragement from your supervisor? (1 ¼ always. 59. Am J Epidemiol 2006. Participants scoring below the median on the scale were coded as having low possibilities for development. Nielsen ML. 2 ¼ usually. social support from coworkers. 2 ¼ usually. European case studies in the workplace. Scoring. social support from supervisors. Kristensen TS. Kristensen TS. Kompier M. Influence at work Items and response categories.18: 305–22. influence at work. 6 ¼ never). Participants scoring 52 points or below on the scale were coded as having severe depressive symptoms. Aust B. Participants scoring 1. Response categories were recoded and summed up to build a scale on possibilities for development. Impact of the psychosocial work environment on registered absence from work: a two-year longitudinal study using the IPAW cohort. 4 ¼ never). de Jonge J. 4 ¼ never. . Rugulies R. Severe depressive symptoms Items and response categories. 6 ¼ none of the time. Comprehensive health promotion interventions at the workplace: experiences with health circles in Germany. 54.30:41–8. 6 ¼ never).53:223–8. Quantitative demands Item and response categories. 3 ¼ usually not. Scores on the scale were standardized from 0 to 100.48: 1149–60. Scoring. Is you work varied? (1 ¼ to a large extent. 3 ¼ 1⁄2 of working hours. Scores on the scale were standardized from 0 to 100. Smith-Hansen L. New York. NY: Routledge. van den Berg AM. 4 ¼ 1⁄4 of working hours. J Occup Health Psychol 2004. Scoring. Scoring.5:11–31.18:323–35. Preventing stress. possibilities for development. Soc Sci Med 1999. Participants scoring 3. 4 ¼ never). Ducki A. 53. Erwachsenenalter. 3 ¼ usually not. or 3 were coded as having high quantitative demands. 5 ¼ do not have a supervisor). job insecurity) were measured in the survey questionnaire and how scores were calculated. 2. Do you have the possibility to learn new things and to qualify yourself at work? (1 ¼ always. Response categories were recoded and summed up to build a scale on depressive mood. Work Stress 2002. with higher scores indicating more influence at work. is it possible for you to decide your work pace? (1 ¼ almost all working hours. 5 ¼ seldom. Scoring. 5 ¼ do not have coworkers). Scand J Public Health 2002. Possibilities for development Items and response categories. The Intervention Project on Absence and Well-being (IPAW): design and results from the baseline of a 5-year study. 3 ¼ usually not. 2 ¼ usually. Do you receive information on those decisions that affect your workplace? (1 ¼ always. How much of the time during the past 4 weeks have you been a very nervous person? How much of the time during the past 4 weeks have you felt so down in the dumps that nothing could cheer you up? How much of the time during the past 4 weeks have you felt calm and peaceful? How much of the time during the past 4 weeks have you felt downhearted and blue? How much of the time during the past 4 weeks have you been a happy person? Response categories for all the preceding questions include the following: 1 ¼ all of the time. with higher scores indicating more possibilities for development. 2 ¼ most of the time. et al. Work Stress 2004.163:877–887 APPENDIX This appendix describes how the endpoint variable (severe depressive symptoms) and the six predictor variables (quantitative demands. Psychother Psychosom Med Psychol 2003. In your work. Do you receive support and encouragement from your coworkers? (1 ¼ always. Aust B. with higher scores indicating less depressive mood. Bjorner JB. J Occup Health Psychol 2000. 2 ¼ 3 ⁄4 of working hours. Are you involved in planning your work? (1 ¼ always. 57. 5 ¼ a little of the time. 3 ¼ 1⁄2 of working hours. 5 ¼ seldom. Social support from supervisors Item and response categories. 2 ¼ usually. Scores on the scale were standardized from 0 to 100. Christensen KB. 4. improving productivity. 56. 3 ¼ 1⁄2 of working hours. The distinction between work pace and working hours in the measurement of quantitative demands.9:258–70. Does your work require that you repeat the same work tasks many times per hour? (1 ¼ almost all working hours. Social support from coworkers Item and response categories. 2 ¼ usually. 60. 3 ¼ usually not. Participants scoring below the median on the scale were coded as having low influence at work. Is your amount of work so extensive that you do not have time to think and talk about anything else than work? (1 ¼ almost all working hours. 4 ¼ never). 4 ¼ some of the time. or only to a small extent). 4 ¼ 1⁄4 of working hours. Hannerz H. 16:191–206. 3 ¼ only to a less extent. Nijhuis FJ. Work Stress 2004. (In German). 58. 3 ¼ a good bit of the time. et al. Response categories were recoded and summed up to build a scale on influence at work. Stress prevention in bus drivers: evaluation of 13 natural experiments. Cooper C. 4 ¼ never. 3 ¼ usually not. Mulder MJ. 55. 5 ¼ seldom. Kompier MAJ. Christensen KB. Borg V. 1999.

Job insecurity Items and response categories. 2 ¼ no). Scoring. Are you worried about any of the following outcomes: becoming unemployed. 4. Participants responding ‘‘yes’’ to at least one item were scored as having job insecurity. 887 being transferred to another job against your will.163:877–887 . becoming redundant because of new technology. Participants scoring 3. having difficulty in securing another job if you became unemployed? (1 ¼ yes. Am J Epidemiol 2006.Psychosocial Work Environment and Depressive Symptoms Scoring. or 5 were coded as having low coworker support.