Stress at workBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2489 (Published 15 June 2017) Cite this as: BMJ 2017;357:j2489
- Thomas Despréaux, chief resident1 2 3,
- Olivier Saint-Lary, general practitioner, senior lecturer4 5,
- Florence Danzin, psychiatrist1 6,
- Alexis Descatha, occupational/emergency practitioner, professor1 2 3
- 1Occupational health unit, University hospital of Poincaré site, Garches, France
- 2Versailles St-Quentin University, Versailles, France
- 3CESP, U 1018 Inserm, Villejuif, France
- 4Versailles Saint-Quentin en Yvelines, Faculty of Health sciences Simone Veil, Department of Family Medicine, Montigny le Bretonneux, France
- 5Université Paris-Saclay, University Paris-Sud, Villejuif, France
- 6Charcot Psychiatric Hospital, France
- Correspondence to O Saint-Lary
What you need to know
Long working hours and strain at work contribute to stress, ill health, and increased risk of cardiovascular diseases, diabetes, and mental illnesses
Explore occupational factors such as an imbalance between effort and reward, work overload, bullying, and job insecurity
Workplace interventions, a short period of leave from work, and psychological treatment can be considered, alongside regular follow-up to assess how the patient is coping
A 55 year old senior executive presents with low back pain. He appears anxious. A reorganisation within his company has increased his workload and he has been working more hours but receiving no recognition from management. Last week he felt humiliated by a colleague. Since then he has not been able to sleep for more than a couple of hours each day.
Stress accounts for more than a third of all cases of work related ill health and almost half of all working days lost due to illness.1 Internationally, systematic reviews and meta-analysis of observational data suggest that job strain and poorly functioning work environments are associated with the development of depressive symptoms.2 3 4 A longitudinal cohort study from Norway found workplace bullying to be associated with subsequent suicidal ideation.5 Long working hours are also associated with increased risk of stroke, heart disease,6 and diabetes,7 and poor lifestyle including inactivity,7 smoking,7 and risky alcohol use.8
Patients might present with unexplained somatic symptoms, such as odd aches and pains, palpitations, loss of appetite, and loss of sleep.9 10 Explore their symptoms and discuss any contributing factors in their work and personal life. The consultation can be long and difficult, as the patient might not volunteer all the information or draw the association with work stress. The objective of this first consultation is to perform a quick risk assessment and explore factors in the patient’s job that are contributing to stress.
What you should cover
The following questions are based on systematic reviews, and the experiences of clinicians and patients.
• the nature and duration of the patient’s presenting symptoms
• associated depressive symptoms, such as
o feeling down, low, or sad
o loss of interest in activities
o tiring easily
o lack of concentration
o changes in sleep and appetite
• feelings of hopelessness, (eg, a belief that the situation cannot improve)11
• occupation, working environment, and stressors at work (box 1)
• the chronology of events, how the patient has coped so far, and if things have changed recently in their workplace. Typically, three phases are described13:
an initial (“serene”) phase, where the patient reports no particular difficulty
a “problem” phase, when obstacles and conflicts gradually appear and the patient tries to deal with the situation
a “crisis” phase, where s/he comes to see you
• protective factors for severity of outcome include a supportive family environment and financial wellbeing. Aggravating factors are familial isolation, being a single parent with young children, having financial difficulties, or being bound by a particular type of employment contract that forces the patient to stay in the same job. The latter can delay diagnosis, and limit the range of remedial options available.
• thoughts of ending their life or causing harm to themselves or others
• other medical illnesses, including diabetes, hypertension, cardiovascular events, or psychiatric disorders
• smoking, alcohol, and drug abuse
• family history of depression or mental disorders, which could increase the risk of depression and suicide
Conflict of values (being asked to do a poor quality job or cut costs for a person who likes to keep high standards in their work)
Feeling insufficiently rewarded compared with the person’s assessment of their efforts (“effort-reward imbalance”)
Inability to make decisions about when or how to stop work
Lack of support from colleagues and management
Isolation at work (no cooperation between teams)
Work overload (working after hours) or insufficient workload (nothing to do)
Discrimination, humiliation, violence, bullying, and harassment at work
Cases of work related stress in the same company
Company situation in terms of finances, organisational changes, and employee turnover
Job insecurity, temporary employment status
Patients come to their doctor primarily to address their symptoms, but some will also want assistance and advice on how to cope with the situation at work.
Assess general appearance and look for signs of psychomotor agitation such as restlessness, rapid talking, and racing thoughts, or of psychomotor retardation such as apparent exhaustion and visible slowing of physical activity. These might indicate a mental illness or organic cause, such as a thyroid disorder.
Perform a quick general examination to look for fever, tachycardia, hypertension, and signs of thyroid disorder (which can be a differential diagnosis). Examine thoroughly for reported pain, though somatisation is likely.
What you should do
Investigation and management of physical and mental health diagnoses—Offer usual management of conditions such as depression. Consider immediate referral to psychiatry if the patient describes suicidal or aggressive thoughts or intentions.
Make the connection between the patient’s experience and work stress—For patients with work related stress and a variety of symptoms, acknowledge their situation and validate their feelings with a phrase such as, “I understand that you are suffering and that this feeling is arising from a stressful work environment.”
Offer a supportive setting to discuss and make progress in dealing with work stress—High quality evidence and guidelines for interventions to manage work related adjustment issues and stress are lacking.14 Cognitive therapy, stepwise reintegration planning, and relaxation training can all be considered.15 16 Therapy needs to be supportive, active, flexible, goal directed, and time bound.10 12 14
Consider offering a second appointment—for example, if there is too much to cover. You might suggest that the patient brings a family member to the next appointment for support.
In the interim, you might ask the patient to reflect on their job and personal situation, and possibly to write a short description of their problems at work, the chronology of these problems, and their relationship to the patient’s symptoms. In our experience, some patients find this helps them reflect on the events, and it can help you understand their situation better. This will help to initiate discussion on strategies that the patient might employ to navigate their workspace going forward. Making contact with the workplace to modify work or reduce workload in collaboration with the employer can be helpful. Discuss whether the occupational health services or human resources division at the patient’s company could be involved. In some circumstances, patients might wish to seek compensation or take legal action. Explore if these are important for your patient and direct them to appropriate agencies or lawyers who can help with these matters.
Consider whether the patient wants or might benefit from time away from work including a “sick note.”
Schedule a follow-up visit to assess how the patient is coping with symptoms and workplace issues, and modify the approach accordingly.
Education into practice
What factors would you typically explore in the patient’s history to understand their working environment and stress? Does this article offer you ideas on how to do so differently?
Sometimes, asking the patient to write down their problems at work, the times at which the problems occurred, and the patient’s symptoms, is helpful. Are there ways in which you might consider using this or other techniques to help patients better organise their thoughts or understand them yourself?
Do you offer a second appointment, if there is too much to cover, or if the patient wishes to include a friend or family member?
In difficult cases, do you work in collaboration with mental health professionals as well as occupational health professionals?
How patients were involved in the creation of this article
Patients in our practice reported a need to rethink what they had experienced at work and to share this in writing. This helped them identify and clearly communicate the chronology of events. Based on their feedback we recommend encouraging patients to write about their work environment and factors contributing to stress, though this need not be mandatory.
A patient reviewed this article and attested that writing a two page memorandum would have been enormously helpful to identify problems at work and how they had escalated over time, and to come to terms with the situation.
We would like to thank Richard Carter for helping us to improve the language of this document.
We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.
We would like to thank Richard Carter for helping us to improve the language of this document.
Patient consent obtained.
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