Are Reports of Psychological Stress Higher in Occupational Studies? A Systematic Review... (2013) Goodwin, Hotopf, Wessely, etc

Esther12 · Oct 8, 2020

I thought that this was of some interest as it has Wessely seeming to be unusually open about the limitations of questionnaires for assessing symptoms/disorders. Though this time that's seemingly partly because it goes against the 'work is good for you' creed used by the UK government (Waddell & Burton's overly influential, and often over interpreted, piece is reference 8).

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078693

Abstract
Objectives
The general health questionnaire (GHQ) is commonly used to assess symptoms of common mental disorder (CMD). Prevalence estimates for CMD caseness from UK population studies are thought to be in the range of 14–17%, and the UK occupational studies of which we are aware indicate a higher prevalence. This review will synthesise the existing research using the GHQ from both population and occupational studies and will compare the weighted prevalence estimates between them.

Methods
We conducted a systematic review and meta-analysis to examine the prevalence of CMD, as assessed by the GHQ, in all UK occupational and population studies conducted from 1990 onwards.

Results
The search revealed 65 occupational papers which met the search criteria and 15 relevant papers for UK population studies. The weighted prevalence estimate for CMD across all occupational studies which used the same version and cut-off for the GHQ was 29.6% (95% confidence intervals (CIs) 27.3–31.9%) and for comparable population studies was significantly lower at 19.1% (95% CIs 17.3–20.8%). This difference was reduced after restricting the studies by response rate and sampling method (23.9% (95% CIs 20.5%–27.4%) vs. 19.2% (95 CIs 17.1%–21.3%)).

Conclusions
Counter intuitively, the prevalence of CMD is higher in occupational studies, compared to population studies (which include individuals not in employment), although this difference narrowed after accounting for measures of study quality, including response rate and sampling method. This finding is inconsistent with the healthy worker effect, which would presume lower levels of psychological symptoms in individuals in employment. One explanation is that the GHQ is sensitive to contextual factors, and it seems possible that symptoms of CMD are over reported when participants know that they have been recruited to a study on the basis that they belong to a specific occupational group, as in nearly all “stress” surveys.
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Introduction
The general health questionnaire (GHQ) is one of the most commonly used measures to assess symptoms of common mental disorder (CMD) in the UK [1]. It has been administered in population studies (e.g. British Household Panel Survey) and more commonly in smaller studies of particular groups, such as occupational studies (e.g. a study of UK doctors [2]) to estimate the level of CMD in a specific population. It is generally believed that there are particular occupational groups who are exposed to a higher level of stress than other occupations, e.g. police officers and military personnel; however, there are few studies comparing rates of CMD across these occupations or to the general population.

[3], [4], with the prevalence of CMD in occupational studies, such as military personnel and London civil servants higher at 20% and 27% respectively [5], [6]. This difference is inconsistent with the ‘healthy worker effect’ and the assumption that healthier individuals are more likely to be selected into work, which is well established [7]. Furthermore, it is conflicting with the fact that there are many aspects of working which have a positive impact on mental health [8]. Occupational samples are also less likely to include the disabled, those with long term physical or mental health disorders, and by definition exclude the unemployed which in itself is a strong risk factor for poor mental health [9].
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Discussion
The main finding of this systematic review is that people appear less likely to report symptoms of CMD in the context of a population based study rather than in a study of the occupational group to which they belong. This difference was reduced but not fully accounted for by differences between these types of studies, in relation to the quality of the studies. This effect is unlikely to reflect true differences in the level of CMD symptoms experienced, because population studies aim to comprise all sections of the population, including those with chronic health problems, long term disabilities and the unemployed, whilst occupational studies will be subject to the health worker effect [7]; so one would anticipate the reverse. There are aspects of work which are associated with increased psychological distress (e.g. high demands and low decision latitude [56]), however, the benefits of employment, over not working, for mental health have consistently been outlined and it is established that the prevalence of CMD is lower in working populations compared to the general population [57]. There were also unexpected findings within the occupational groups: occupations for which one would expect a higher level of traumatic events, such as the military and police, were not found to have a higher prevalence of CMD than other occupational groups, including academics, teachers, white collar workers and social services staff.

We propose that studies directed at the mental health or “stress levels” of particular occupations may be subjected to a systematic bias, one that is not present in true population studies when participants are not selected purely because they belong to a specific occupation. Numerous occupational studies are actually labelled as studies of “work stress”, which may give rise to a framing effect. There is evidence for strong contextual effects in previous experimental and observational studies [58], [59], [60], [61], which can be defined as the effect of environmental factors on subjective outcomes, in addition to bias in self-report psychological measures [62]. The setting in which a questionnaire is completed is likely to influence responses. Responses in the occupational studies may have been biased by a framing effect [63], with the emphasis on job related questions potentially leading to individuals venting their work frustrations through questionnaires which provide an opportunity to report dissatisfaction. This framing effect may be heightened, or conversely lessened, depending on where the GHQ is embedded within the questionnaire and its positioning relative to other psychosocial measures.
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Implications
The primary implication of this research relates to the sensitivity of the GHQ, which asks about ‘recent’ symptoms of mental health, to factors other than objective mental health and to the potential framing effect resulting from the overall narrative of a questionnaire or interview. However, we suggest that other self-reported measures of mental health may be subject to contextual effects, and that interpreting the results of any single study without considering the context in which it was given, and the possible bias that introduces, may lead to flawed conclusions. Hence for example, if an individual reports higher levels of psychological symptoms within the context of an occupational study, this may be a reflection of dissatisfaction with their job as opposed to reflecting depression or unhappiness with their life outside of work. These types of effects have previously been shown in individual studies, but we have systematically reviewed evidence across a range of studies. The elevated levels of CMD evidenced in occupational studies may be reduced if mental health is assessed separately to job satisfaction and other occupational constructs and thought should be given as to where the mental health measures are incorporated in a questionnaire.
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Hutan · Oct 8, 2020

We propose that studies directed at the mental health or “stress levels” of particular occupations may be subjected to a systematic bias, one that is not present in true population studies when participants are not selected purely because they belong to a specific occupation. Numerous occupational studies are actually labelled as studies of “work stress”, which may give rise to a framing effect. There is evidence for strong contextual effects in previous experimental and observational studies [58], [59], [60], [61], which can be defined as the effect of environmental factors on subjective outcomes, in addition to bias in self-report psychological measures [62]. The setting in which a questionnaire is completed is likely to influence responses.
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However, we suggest that other self-reported measures of mental health may be subject to contextual effects, and that interpreting the results of any single study without considering the context in which it was given, and the possible bias that introduces, may lead to flawed conclusions.
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Excellent find, Esther12.

Hutan · Oct 8, 2020

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078693
open access

Esther12 · Oct 8, 2020

Hutan said: ↑

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078693
open access
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Oops - I've edited that in to my first post. Don't know how I forgot to post a link. Thanks.

rvallee · Oct 8, 2020

Esther12 said: ↑

I thought that this was of some interest as it has Wessely seeming to be unusually open about the limitations of questionnaires for assessing symptoms/disorders.
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Funny because when the nanoneedle paper came out, one of his comments was that this is probably not necessary since they do just fine diagnosing us with the usual questionnaires and talking to. Even though he readily admits to the opposite, and everything in-between. It's easy to be right by taking all possible perspectives, but normally what's supposed to follow is never being taken seriously again.

Mithriel · Oct 9, 2020

The main finding of this systematic review is that people appear less likely to report symptoms of CMD in the context of a population based study rather than in a study of the occupational group to which they belong.
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They did not get the answer they wanted so they say that it was because patients did not report the symptom, not that the findings of the study are correct. Because the study did not confirm their beliefs it had to be that the questionnaires were not filled in properly.

So questionnaires can be trusted when they give the right answer but not otherwise.

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