Review of the exposure to workplace bullying and harassment in relation to depression and other mental health disorders (such as stress reactions)
Introduction
Labour Market Insurance and the Occupational Diseases Committee find that there is a need for a review in the form of a scientific reference document on the impact of workplace bullying and harassment in relation to the development of depression and other exposure-related mental health disorders as new knowledge may be available. The reference document should also include workplace stress such as allegations, accusations and negative media coverage.
The scientific reference document is to provide an update on knowledge about whether job-related exposure to bullying, harassment, allegations, accusations and negative media coverage will be able to cause depression and other mental health disorders (such as stress reactions). Research on bullying and harassment was most recently conducted in 2015, and new research evidence on this type of exposure in relation to the development of depression and other mental health disorders (such as stress reactions) may now be available.
An assessment is requested of whether there is any documentation for a causal relationship between the exposure to bullying, harassment, allegations, accusations and negative press coverage in relation to developing depression and other mental health disorders such as stress reactions. An assessment of whether there is any new knowledge about the exposure requirements is also requested (type, scope and duration of the exposure as well as latency from exposure until the development of symptoms). The focus must be especially on the type and duration of the exposure as well as on a quantitative assessment of the correlation between exposure level and development of the disease.
A description of how the mental strain/level of exposure can be defined is needed as well as a description of what the minimum exposure requirement is for such exposure to cause disease.
What is also needed is a description of any competing diseases/conditions, such as hereditary factors, private stress factors, personality disorder and individual vulnerability factors (such as previous mental health disorder, exposure to mental violations at home, a close person’s illness or the loss of such person and divorce).
Background
Labour Market Insurance and the Occupational Diseases Committee have looked into whether there is a basis for a new review report on the exposure to bullying and harassment etc. and the development of depression and other mental health disorders (such as stress reactions). Since the job-related exposure to bullying and harassment was discussed in connection with the MODENA research project in 2015, a number of scientific articles have been published which are deemed to provide a potential for adding new knowledge about these types of exposure. A review report within this field will be relevant as will an evidence-based clarification of what types and what severity degrees of exposures can cause depression and other mental health disorders (such as stress reactions).
The MODENA project looked into the correlation and any causality between workplace bullying and an increased risk of depression and sleep disorders. The final report was based partly on the results of questionnaire replies from two extensive, prior projects (the MCA project and the PRISME project), partly on a study of the persons involved in these preceding projects.
Labour Market Insurance and the Occupational Diseases Committee discussed the results of the project in 2015, and the Committee concluded that the study could not constitute a basis for including depression and other mental health disorders caused by exposure to bullying in the List of Occupational Diseases. The reason is that the project did not unambiguously reach any conclusion on the extent to which a person must be exposed to bullying for such bullying to cause depression, and it was therefore impossible to conclude that there is causal relation. This was especially due to the lack of documentation that the bullying had taken place. The Occupational Diseases Committee found no basis for altering its existing understanding that a mental disease may be caused by excessive stress impacts in the workplace. The Occupational Diseases Committee therefore continued its practice of recommending that workers’ compensation claims relating to mental health disorders caused by exposure to bullying should be recognised as an industrial injury on the basis of a specific assessment of the special nature of work.
Project framework
Against the background of a primarily epidemiologically based examination of the most substantial Danish and international research results in the relevant field, the scientific reference document must elucidate in detail, summarise and assess knowledge about the risk of developing depression and other mental health disorders (such as stress reactions) caused by exposure to different types and different severity degrees of bullying, harassment, allegations, accusations and negative media coverage. Against the background of the nature and duration of the exposure (i.e. the type, scope and duration of the exposure – as well as the latency period from exposure until the development of symptoms) and competing factors, the document must include a description of the statistical correlation and an evidence assessment.
What is required is a specific comparison of surveys across various research designs, including longitudinal surveys, case-control surveys as well as various types of measures of exposure.
Applicants must give an account of how they intend to consider all the questions raised. In the event that the applicant finds it impossible to answer as required all the questions raised, the applicant is asked to describe an alternative method to be used in the review or perhaps in a subsequent survey (not comprised by the review).
For possibly work-related depression and other mental health disorders (such as stress reactions), the following information is required:
About the disease
• Diagnostic delimitation and specification of depression and other mental health disorders (such as stress reactions)
• Information about how the diagnosis was made
• An assessment of the validity of the survey results
• Information about the severity of the disease/symptoms
• Comorbidities
About the exposure
• The general nature of the exposures (the types of work in question)
• The more specific nature and intensity/scope of the exposures, compared with an assessment of the size of the risk
• The total exposure duration over time (accumulated exposure, latency and possible aggravation after the exposure has ended)
• Description of the nature and scope as well as duration of the occupational exposures
• Correlation between the nature, scope and duration of the exposure and the risk of developing a depression or other mental health disorders (such as stress reactions)
About dose-response correlation and latency
• Summarising description and assessment of the type, scope and duration of the exposure
• Description and assessment of the onset time in relation to exposure as well as the latency period from exposure until the development of symptoms
• Assessment of the disease prognosis and the significance of the exposure for the prognosis
About competing and pre-existing diseases/factors
• Description of the significance of competing and pre-existing diseases for the disease development in question
• Description of the significance of non-occupational, including private exposures
• Descriptions of the significance of other, non-occupational factors (for instance inheritance, gender, age and other diseases)
• Quantitative assessment of the role played by occupational exposures in the development of the disease, in relation to non-occupational diseases/factors
Summary
• Description and assessment of the reliability of the exposure and disease documentation in the individual article
• Summarised and graduated assessment of the evidence (see special guidelines for reviews of occupational diseases)
• The project report will include an explanatory summary in Danish, addressed to lay persons
If the available literature is inadequate for the elucidation of the requested causalities, this is to be stated, substantiated and specified.
If, in this connection, it is found that additional research should be initiated, the relevant efforts and goals for further research should be pointed out, substantiated and included in the overall conclusion of the project.
Special guidelines
The preparation of the review must follow the special guidelines for preparation and quality approval of reviews in the form of reference documents in the field of occupational diseases. The current edition of the guidelines is found below.
|
Special guidelines for preparation and quality approval of reviews in the form of reference documents in the field of occupational diseases (Labour Market Insurance) |
|
|
|
Further reference is made to the current standard terms for subsidies from the Working Environment Research Fund. These standard terms also apply to the preparation of reference documents. |
Guidelines for establishing a reference document
on the causal association between an occupational exposure
and a disease outcome
(The Working Environment Research Fund)
Guidelines for manuscripts of reference documents
The aim of establishing a reference document is to provide the best evidence-based answers to questions on the causal relations between an occupational exposure and a disease outcome.
The reference document should be written in English and should be supplied with an extended popular summary. The text part of this summary will be translated to Danish. The reference document, tables and appendices will not be translated.
The reference document should be written in a form, which is suitable for publication in a peer-reviewed international journal. The word count of the main text should not exceed 8000 words. If the requirements outlined below (e.g. text summaries of key studies) imply that the review becomes too long for such a publication, some of the detailed information may be put in an appendix and only summarized in the main text.
The manuscript should be organised as follows:
- Background and delimitations of the task to specific diagnoses and exposures
- The outcome under study
- Clinical diagnosis and proxy-measures used in epidemiological studies.
- Exclusions of certain conditions from the study.
- Risk factors for the outcome (excluding the exposure under study).
- Descriptive epidemiology, incidences and prevalences of the outcome.
Preferably, literature references in this section should be to high quality reviews rather than original papers, since this introductory section is not based on a separate literature review by the authors.
This section should be oriented towards problems to be discussed in subsequent sections.
- The exposure under study
- Definition of the exposure.
- Measurement of the exposure.
- Distribution in the general population and occupational groups.
Preferably, literature references in this section should be to high quality reviews for the reasons given above.
This section should be oriented towards problems to be discussed in subsequent sections.
- Literature search
- Description of search terms, databases searched, date of final search and number of references.
- Description of the procedures followed to arrive at the studies that are considered in the document (inclusion and exclusion criteria and the methods used to apply them).
- If the final set of references includes a large number of studies (e.g. more than 25-30 studies per outcome) it is recommended to include only the studies that are most informative with respect to the issue (key studies). The procedure used to get to these studies must be described and documented.
- A flow-diagram of the literature selection should be included.
- Literature review
The final set of references from the literature search should be described in text and tables, study by study. The text should shortly present essential details of the study and provide the reader with a good impression of its distinguishing features, strengths and limitations, and should include evaluative comments by the authors on the reference document. More important studies are presented with more detail than less important ones. Critical comments on the individual study should be given [in square brackets] in this section.
If there are more than 25-30 references per outcome, only the key studies on which the conclusion is based need to be described in the text. The remaining articles should be described in an independent table corresponding to the table of the more informative studies. The purpose of this selection is to move quickly to the more important studies and not having the presentation mixed up with detailed descriptions and results from less informative studies.
- Quality assessment of a specific study
In addition to systematic assessments of the quality of the study by using formal scoring systems, reviewers are encouraged to qualitatively assess the results of each study with respect to the likelihood that they may reflect chance, bias or confounding, and to assess the external validity of the study results. Quality should not be assessed only by a formal scoring system since there is no ‘gold standard’ for the true validity of a study.
- Other relevant data
Other relevant data from human or animal, observational or experimental studies should be referred to. The assessment of plausible disease mechanisms to support a cause-effect relation may typically rest on such contributing evidence. The description of contributing evidence may rely on good reviews rather than original studies.
- Discussion
The discussion should consider the whole set of results from the studies included in the reference document, and especially consider the degree to which it may be assumed that bias or confounding could explain the overall results. The discussion should aim at clarifying the main arguments pertinent to the overall conclusion on causality based on the literature review.
The discussion should deal with the diagnostic entities used in the epidemiological studies in the review compared to diagnostic criteria in clinical practice, the reliability and validity of the outcome measures used in different studies.
The discussion should further deal with problems of exposure assessment relevant to the problem, including reliability and validity. Inaccuracies in diagnosis or exposure assessment should be discussed with respect to the direction and magnitude of the resulting bias of the exposure-outcome relation.
Furthermore, the discussion should consider the effects of potential confounding or effect modification which was not accounted for, and the degree to which the overall results may be influenced by such uncontrolled confounding or effect modification.
The different arguments relating to bias and confounding of the relation between outcome and exposure should be detailed and summed up in a manner that clearly explains and justifies the conclusion.
- Conclusion
The conclusion should start by describing the premises on which it is made. It should be a natural extension of the discussion and shortly declare the degree of evidence for a causal association between the outcome and exposure under consideration. The degree of evidence is described with a view to the classification scheme on the last page of these guidelines, but must verbally reflect the opinions of the authors in sufficient detail. However, the conclusion should be short and to the point. If it is concluded that there is strong or moderate evidence of a causal exposure-effect relationship, the exposure-response pattern of this relationship should be described – and if possible, translated to a practically useful exposure measure. If several outcomes or exposures are included in the review, there must be a conclusion for each specific relation.
- Abstract
- Extended popular summary
The extended summary must give an accurate account of the work and especially focus on an argued response to the questions raised in the task description. The language should be straightforward and technical terms should be avoided. The summary is aimed at informing the organisation funding the report, decision makers and the public at large on the background, results and conclusions of the work. The extended popular summary will be translated to Danish.
Degree of evidence of a causal association between an exposure to a specific risk factor and a specific outcome
The following categories are used:
+++ Strong evidence of a causal association
++ Moderate evidence of a causal association
+ Limited evidence of a causal association
0 Insufficient evidence of a causal association
- Evidence suggesting lack of a causal association
Strong evidence of a causal association (+++):
A causal relationship is very likely. A positive relationship between exposure to the risk factor and the outcome has been observed in several epidemiological studies. It can be ruled out with reasonable confidence that this relationship is explained by chance, bias or confounding.
Moderate evidence of a causal association (++):
A causal relationship is likely. A positive relationship between exposure to the risk factor and the outcome has been observed in several epidemiological studies. It cannot be ruled out with reasonable confidence that this relationship can be explained by chance, bias or confounding, although this is not a very likely explanation.
Limited evidence of a causal association (+):
A causal relationship is possible. A positive relationship between exposure to the risk factor and the outcome has been observed in several epidemiological studies. It is not unlikely that this relationship can be explained by chance, bias or confounding.
Insufficient evidence of a causal association (0):
The available studies are of insufficient quality, consistency, or statistical power to permit a conclusion regarding the presence or absence of a causal association.
Evidence suggesting lack of a causal association (-):
Several studies of sufficient quality, consistency and statistical power indicate that the specific risk factor is not causally related to the specific outcome.
Comments:
The classification does not include a category for which a causal relation is considered as established beyond any doubt.
The key criterion is the epidemiological evidence.
The likelihood that chance, bias and confounding may explain observed associations are criteria that encompass criteria such as consistency, number of ‘high quality’ studies, types of design etc.
Biological plausibility and contributory information may add to the evidence of a causal association.