Review of the impact in relation to post-traumatic stress syndrome (PTSD) and other exposure-related mental health disorders

Review of the impact in relation to post-traumatic stress syndrome (PTSD) and other exposure-related mental health disorders

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 criterion for post-traumatic stress syndrome (PTSD) and other exposure-related mental health disorders as new knowledge may be available.

The project notice has been divided into two parts because it is an extensive project, but at the same time the two parts of the project probably involve some of the same studies and surveys. The project may be handled as one project or as two reports. The criteria listed below relating to the ‘project framework’ must be complied with in both part 1 and part 2. 

Pay attention to the deadline for finalizing the scientific reference document. See below under "project framework".

Part 1

The scientific reference document is to provide an update on what types of exposures can cause PTSD. The review report must include exposures that may occur in all occupations and not exposures that specifically occur within a certain profession. It has been found that, based on recent knowledge, the exposure criteria for PTSD might include traumatic events that are smaller in extent than the exposure criterion applied according to ICD-10 until now. This could involve, for example, mental violations/mental strain in the workplace such as violence, threats, bullying, harassment and vicarious traumatisation etc. of a lower degree of severity than criteria applied until now. That is the reason why a detailed review of the exposure in relation to PTSD is requested.

An assessment is requested of whether there is any documentation of a causal relation between specific types of mental strain and the development of the disease PTSD, including whether new knowledge about the exposure requirements (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 requested as well as a description of what the minimum exposure requirement is for such exposure to cause the disease. 

What is also needed is a description of any competing diseases/conditions, for example hereditary factors, personality disorder and individual vulnerability factors (such as previous mental health disorder, physiological conditions and exposure to mental violations at home, a close person’s illness or the loss of such person, and divorce).

 
Part 2

In addition to a review of what mental exposure may cause PTSD, Labour Market Insurance and the Occupational Diseases Committee request a description of whether the exposure that may cause PTSD may also cause other exposure-related mental health disorders. This could be, for example, unspecified stress reaction or depression. In the same manner as in part 1, traumatic events that are smaller in extent than the exposure criterion in relation to PTSD and ICD-10 may be involved. The reason is that, in March 2019, the Occupational Diseases Committee discussed the scientific reference document ‘Vold på arbejdspladsen og psykiske helbredskonsekvenser: Et systematisk review med metaanalyse’ (violence in the workplace and mental health consequences: a systematic review with meta-analysis) from December 2018. However, the research group was not able to specifically look into whether the disease unspecified or other stress reaction occurred in relation to incidents involving violence and threats. The reason is that the exposure was part of the diagnosis. But contrary to PTSD, there was not no clearly specified exposure requirement in the ICD-10 diagnosis criterion for the unspecified/other stress reaction. As the 2018 review did not present more specific knowledge about exposure types in relation to unspecified stress reaction, this review is requested to clarify whether, at this point in time, it will now be possible to clarify the exposure in further detail. If possible, a description is therefore requested of what other exposure-related mental health disorders that the patients have developed as a result of exposures (possibly taking into account the same studies as in part 1) – including an elaboration of what exposures are involved. Other diseases could be depression or the equivalent of what we in Denmark call ‘unspecified stress reaction F43.9’, cf. ICD-10 of the English version of ICD-10: ‘Reaction to severe stress, unspecified’ and in the US diagnosis system DSM-V: ‘Post-traumatic stress disorder’, ‘Acute stress disorder’, ‘Adjustment disorders’, “Reactive attachment disorder’, ‘Disinhibited social engagement disorder’, ‘Unclassified and unspecified trauma disorders’). The Occupational Diseases Committee will then subsequently assess in further detail whether knowledge can be transferred to the Danish diagnosis codes.

An assessment is requested of whether there is any documentation of a causal relation between specific types of mental strain and the development of exposure-related mental health disorders, including whether there is there is any new knowledge about the exposure requirements (type of exposure, scope and duration 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 requested as well as a description of what the minimum exposure requirement is for such exposure to cause the disease. 

What is also needed is a description of any competing diseases/conditions is also requested, for example hereditary factors, personality disorder and individual vulnerability factors (such as previous mental health disorder, physiological conditions and exposure to mental violations at home, a close person’s illness or the loss of such person, and divorce).

Background

In IDC-10, the exposure criterion is described as ‘a traumatic event or situation (of short or long duration) of an exceptionally threatening or disastrous nature’ which will cause a strong impact on practically everybody. There are big variations in terms of how the exposure criterion is understood by medical specialist in psychiatry. The trend has generally been towards including less exceptional exposures as causes of PTSD throughout the years ICD-10 has been in force.

Labour Market Insurance and the Occupational Disease Committee have looked into whether there is a basis for a more detailed examination of the exposure in a new review. The latest reviews on PTSD have mainly focused on delayed PTSD and time correlation. The change in the time criteria for PTSD have brought into focus several types of exposure in all occupations which were previously rejected because of lack of time correlation. Labour Market Insurance has made an overall search of scientific articles for new information on the subject. Since the nature of exposure was discussed in connection with the inclusion of PTSD in the List of Occupational Diseases in 2005, a number of scientific articles have been published on the exposures, including different types of exposure in relation to PTSD. It will be relevant with a review in this field and an evidence-based clarification of what types and what severity degrees of exposures can cause PTSD and other exposure-related mental health disorders.

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 of the risk of developing PTSD and other exposure-related mental health disorders upon exposure to different types and different severity degrees of traumatic exposures. Against the background of the nature and duration of the exposure (exposure criteria – 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 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.

It is a requirement that the scientific reference document can be completed and submitted to AMFF by spring 2026 at the latest.

Applicants must give an account of how, in their review, they will 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 PTSD and other exposure-related mental health disorders, the following information is required:

About the disease
•    Diagnostic delimitation and specification of PTSD or other exposure-related mental health disorders
•    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)
•    A 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 
•    PTSD or other exposure-related mental health disorders

About dose-response correlation and latency
•    Summarising description and assessment of the type, scope and duration of the exposure
•    Description and assessment of 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.

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:

1.    Background and delimitations of the task to specific diagnoses and exposures

2.    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.

3.    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.

4.    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.  

5.    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. 

6.    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. 

7.    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. 

8.    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. 

9.    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. 

10.    Abstract

11.    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 straight forward and technical terms should be avoided. The summary is aimed at informing the organisation funding the work, 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

Description of categories:
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.