Stress and psychiatric disorder in healthcare professionals and hospital staff

Summary

Background

Previous studies of stress in healthcare staff have indicated a probable high prevalence of distress. Whether this distress can be attributed to the stressful nature of the work situation is not clear. No previous study has used a detailed interview method to ascertain the link between stress in and outside of work and anxiety and depressive disorders.

Methods

Doctors, nurses, and administrative and ancillary staff were screened using the general health questionnaire (GHQ). High scorers (GHQ>4) and matched individuals with low GHQ scores were interviewed by means of the clinical interview schedule to ascertain definite anxiety and depressive disorders (cases). Cases and controls, matched for age, sex, and occupational group were interviewed with the life events and difficulties schedule classification and an objective measure of work stress to find out the amount of stress at work and outside of work. Sociodemographic and stress variables were entered into a logistic-regression analysis to find out the variables associated with anxiety and depressive disorders.

Findings

64 cases and 64 controls were matched. Cases and controls did not differ on demographic variables but cases were less likely to have a confidant (odds ratio 0·09 [95% CI 0·01–0·79]) and more likely to have had a previous episode of psychiatric disorder (3·07 [1·10–8·57]). Cases and controls worked similar hours and had similar responsibility but cases had a greater number of objective stressful situations both in and out of work (severe event or substantial difficulty in and out of work—45 cases vs 18 controls 6·05 [2·81–13·00], p<0·001; severe chronic difficulty outside of work—27 vs 8, 5·12 [2·09–12·46], p<0·001). Cases had significantly more objective work problems than controls (median 6 vs 4, z=3·81, p<0·001). The logistic-regression analyses indicated that even after the effects of personal vulnerability to psychiatric disorder and ongoing social stress outside of work had been taken into account, stressful situations at work contributed to anxiety and depressive disorders.

Interpretation

Both stress at work and outside of work contribute to the anxiety and depressive disorders experienced by healthcare staff. Our findings suggest that the best way to decrease the prevalence of these disorders is individual treatment, which may focus on personal difficulties outside of work, combined with organisational attempts to reduce work stress. The latter may involve more assistance for staff who have a conflict between their managerial role and clinical role.

Introduction

Numerous studies have shown high amounts of psychological distress in doctors, nurses, and other healthcare professionals working in various situations.1, 2, 3, 4, 5, 6, 7, 8 In the UK, 20 reports have indicated that a quarter to a half of the National Health Service (NHS) staff report distress,⁹ which may be a higher rate than that of comparable occupations.8, 9, 10 In different studies, increased psychological distress has been associated with heavy workload and its effect of home life, pressure of work, complaints from patients and relatives, risk of violence, poor management style, inadequate resources, insufficient training, lack of control over work, low involvement in decision-making, low job satisfaction, and harassment.⁹ The findings are not always consistent, however, and the research can be criticised because of measurement issues3, 11, 12 and failure to examine stress outside of work as a causal factor for the distress.13, 14, 15

Nearly all studies have used self-administered questionnaires to assess both psychological distress and work stress. There are two problems with this method. First, a high rate of distress does not correspond with the clinically important anxiety or depressive disorders, which occur at about half the rate of self-reported distress.16, 17 Second, the use of self-administered questionnaires to measure distress and work stress may lead to spurious associations, in which distressed respondents perceive their workload as heavier and their work situation as more stressful than non-distressed respondents, who are functioning well in the same situation.3, 12, 18, 19, 20 To clarify the link between stress and depression, use of objective measures of both is necessary.²¹ One study of American senior managers found that the stresses related to depressive disorder (measured by research interview) were fewer and more specific than the wide range of stressful factors associated with symptoms of distress.²⁰

Despite the suggestions that stress outside of the work situation may be important,22, 23 few studies of healthcare staff have included stress outside of work or personal vulnerability, both of which have been associated with depression in other workforce studies20, 24, 25 and in community studies of depression.²⁶ If we are to reduce stress-related time off work it is important to have a clearer idea of the sources of stress that are associated with anxiety and depressive disorders in healthcare professionals and hospital staff.

We did a case-control study to identify work and other factors associated with anxiety and depressive disorders, with cases and controls identified by research interview by means of a cross-sectional survey. We hypothesised that stress outside of work would be the principal factor differentiating cases of anxiety and depressive disorders from non-distressed controls and, once this factor was accounted for, work variables would not be important.