Effort-reward imbalance, procedural injustice and relational injustice as psychosocial predictors of health: complementary or redundant models?

Psychosocial work environment and stress-related disorders, a systematic review

BACKGROUND

Knowledge on the impact of the psychosocial work environment on the occurrence of stress-related disorders (SRDs) can assist occupational physicians in the assessment of the work-relatedness of these disorders.

AIMS

To systematically review the contribution of work-related psychosocial risk factors to SRDs.

METHODS

A systematic review of the literature was carried out by searching Medline, PsycINFO and Embase for studies published up until October 2008. Studies eligible for inclusion were prospective cohort studies or patient-control studies of workers at risk for SRDs. Studies were included in the review when data on the association between exposure to psychosocial work factors and the occurrence of SRDs were presented. Where possible, meta-analysis was conducted to obtain summary odds ratios of the association. The strength of the evidence was assessed using four levels of evidence.

RESULTS

From the 2426 studies identified, seven prospective studies were included in this review. Strong evidence was found that high job demands, low job control, low co-worker support, low supervisor support, low procedural justice, low relational justice and a high effort-reward imbalance predicted the incidence of SRDs.

CONCLUSIONS

This systematic review points to the potential of preventing SRDs by improving the psychosocial work environment. However, more prospective studies are needed on the remaining factors, exposure assessment and the relative contributions of single factors, in order to enable consistent assessment of the work-relatedness of SRDs by occupational physicians.

Effort-reward imbalance at work and psychological distress: a validation study of post-myocardial infarction patients

OBJECTIVES

To examine whether the psychometric properties of the effort-reward imbalance (ERI) at work scales could be replicated with post-myocardial infarction (post-MI) patients and to measure the criterion validity through its association with psychological distress.

METHODS

A cross-sectional survey was conducted among 814 patients (739 men and 75 women) who had returned to work after their first MI and who were followed up by telephone at an average of 2.2 years after their baseline interview (1998-2000). The psychological demands scale of the Karasek Job Content Questionnaire was used to measure effort. Reward was measured with nine items from the original reward scale by Siegrist plus two proxy items. Exploratory and confirmatory factor analyses were used to test the theoretical structure of ERI. Using log-binomial regression models, we evaluated the association between ERI scales and psychological distress measured with the 14-item Psychiatric Symptom Index.

RESULTS

ERI scales and subscales demonstrated adequate internal consistencies. Exploratory factor analysis using oblique (promax) rotation yielded a three-factor solution with items representative of extrinsic effort (Factor 1) and reward subscales (Factors 2 and 3). Confirmatory factor analysis demonstrated a good fit with the data. The internal consistencies and discriminant validities of the ERI scales were satisfactory. Furthermore, effort, reward, and ERI ratio were significantly associated with psychological distress (adjusted prevalence ratio [PR] = 1.71, 95% confidence interval [CI] = 1.26-2.31; PR = 1.63, 95% CI = 1.16-2.29; and PR = 1.70, 95% CI = 1.17-2.47, respectively).

CONCLUSIONS

The psychometric properties of the ERI scales were generally reproduced among post-MI patients. The associations with psychological distress supported the criterion validity of the ERI scales in this population.

What do we know about the non-work determinants of workers' mental health? A systematic review of longitudinal studies

Background

In the past years, cumulative evidence has convincingly demonstrated that the work environment is a critical determinant of workers' mental health. Nevertheless, much less attention has been dedicated towards understanding the pathways through which other pivotal life environments might also concomitantly intervene, along with the work environment, to bring about mental health outcomes in the workforce. The aim of this study consisted in conducting a systematic review examining the relative contribution of non-work determinants to the prediction of workers' mental health in order to bridge that gap in knowledge.

Methods

We searched electronic databases and bibliographies up to 2008 for observational longitudinal studies jointly investigating work and non-work determinants of workers' mental health. A narrative synthesis (MOOSE) was performed to synthesize data and provide an assessment of study conceptual and methodological quality.

Results

Thirteen studies were selected for evaluation. Seven of these were of relatively high methodological quality. Assessment of study conceptual quality yielded modest analytical breadth and depth in the ways studies conceptualized the non-work domain as defined by family, network and community/society-level indicators. We found evidence of moderate strength supporting a causal association between social support from the networks and workers' mental health, but insufficient evidence of specific indicator involvement for other analytical levels considered (i.e., family, community/society).

Conclusions

Largely underinvestigated, non-work determinants are important to the prediction of workers' mental health. More longitudinal studies concomitantly investigating work and non-work determinants of workers' mental health are warranted to better inform healthy workplace research, intervention, and policy.

Justice at work and psychiatric morbidity among the personnel of an Italian hospital

This study evaluated the association between justice in the workplace (and other psychosocial factors) and mental health among healthcare professionals. It was conducted in a sample of hospital employees in Italy. The prevalence of mental disorders was assessed and the relationships between having a disorder and the level of perceived justice, job control and effort-reward imbalance were investigated. Psychiatric morbidity among professionals with higher perceived justice were 0.3-0.9 times lower than those among those with lower perceived justice. This finding suggests that improving fairness at work does matter for disease prevention and mental health promotion policy.

Work related factors and sick leave after rehabilitation in burnout patients: experiences from the REST-project

INTRODUCTION

The aim of this study was to investigate the impact of psychosocial working conditions and coping strategies at work on change in sick leave level for patients on long-term sick leave due to burnout.

METHODS

A cohort sample of patients (n = 117) on long-term sick leave due to burnout was analyzed. The patients answered a questionnaire at baseline and sick leave information was collected from the Swedish Social Insurance Agency at baseline and at follow-up 2 years later. Two groups were formed depending on whether the patients had "improved" and reduced their sick leave level (56%) or if the sick leave level was "unchanged" (44%) at follow-up. The association between change in sick leave and predictors measuring psychosocial working conditions and coping strategies at work were analyzed using logistic regression.

RESULTS

The predictor, low control at work, was associated with unchanged sick leave at follow-up. When background characteristics were taken into account, usage of covert coping towards supervisors and covert coping towards workmates, respectively, also predicted unchanged sick leave level. High overcommitment was of borderline significance and associated with a reduced sick leave level at follow-up.

CONCLUSIONS

Patients with burnout who have experienced low control at work and used covert coping towards supervisors and/or workmates have a higher risk of not reducing their sick leave after rehabilitation. The workplace may contribute to a reduction of sick leave lengths with a more flexible work environment and improvement in communication strategies for employees and supervisors.

Do positive psychosocial work factors protect against 2-year incidence of long-term sickness absence among employees with and those without depressive symptoms? A prospective study

OBJECTIVE

This study sought to examine the influence of protective work factors on long-term sickness absence among employees reporting different levels of depressive symptoms in a representative sample of the Danish workforce.

METHODS

Questionnaire data were collected from a random sample of members of the Danish workforce aged between 18 and 64 years using information from two surveys with baselines in 2000 and 2005. From the year 2000 baseline, questionnaires from 5510 employees (2790 males and 2720 females) were included; from the 2005 baseline, questionnaires from 8393 employees (3931 males and 4462 females) were included. Baseline data were collected on depressive symptoms, leadership, colleague support, and decision latitude. Information on 2-year incidence of sickness absence was derived from an official register.

RESULTS

Stratified analyses on depressive symptom scores (none, moderate, and severe) indicate that quality of leadership was associated with reduced sickness absence to a somewhat stronger degree for those with moderate depressive symptoms (adjusted hazard ratio=0.88, 95% confidence interval=0.78-0.98) than for those without depressive symptoms and that high decision latitude was associated with reduced sickness absence to a somewhat larger degree for those without depressive symptoms (adjusted hazard ratio=0.91, 95% CI=0.85-0.97) than for those with depressive symptoms. However, quality of leadership and decision latitude did not interact significantly with depressive symptom status.

CONCLUSIONS

Quality of leadership may protect against long-term sick leave to a certain degree in those with moderate depressive symptoms. Possible interactions between psychosocial working conditions and depression status should be investigated in larger populations.

Association of contractual and subjective job insecurity with sickness presenteeism among public sector employees

OBJECTIVE

We examined the associations of contractual job insecurity (fixed-term vs permanent employment contract) and subjectively assessed job insecurity with sickness presenteeism among those who had no sickness absences during the study year.

METHODS

Survey data from a sample of 18,454 Public sector employees were gathered in 2004 (the Finnish Public Sector study).

RESULTS

Fixed-term employees were less likely to report working while ill (odds ratio = 0.88, 95% confidence interval = 0.77 to 0.99) than permanent employees. Subjective insecurity was associated with higher levels of working while ill, and this association was stronger among older employees. These results remained after adjustments for demographics, health-related variables, and optimism.

CONCLUSIONS

Our results suggest that subjective job insecurity might be even more important than contractual insecurity when a public sector employee makes the decision to go to work despite feeling ill.

Job strain predicts recurrent events after a first acute myocardial infarction: the Stockholm Heart Epidemiology Program

OBJECTIVES

Studies investigating the prognostic role of job stress in coronary heart disease are sparse and have inconclusive findings. We aimed (i) to investigate whether job strain predicts recurrent events after acute myocardial infarction (AMI) and if so (ii) to determine behavioural and biological factors that contribute to the explanation of this association.

DESIGN

Prospective study.

SETTING

Ten emergency hospitals in the larger Stockholm area, Sweden.

SUBJECTS

Non-fatal AMI cases from the Stockholm Heart Epidemiology Program case-control study who were employed and younger than 65 years at the time of their hospitalization (n = 676).

RESULTS

During the 8.5 year follow-up, 155 patients experienced cardiac death or non-fatal AMI; totally 96 patients died, 52 of cardiac causes. After adjustment for potential confounders, patients with high job strain had an increased risk for the combination of cardiac death and non-fatal AMI relative to those with low job strain, the hazard ratio (HR) and the 95% confidence interval (CI) being 1.73 (1.06-2.83). Results were similar for cardiac [HR (95% CI): 2.81 (1.16-6.82)] and total mortality [HR (95% CI): 1.65 (0.91-2.98)]. We found no evidence for mediation from lifestyle, sleep, lipids, glucose, inflammatory and coagulation markers on the association between job strain and the combination of cardiac death and non-fatal AMI.

CONCLUSIONS

Job strain was associated with poor long-term prognosis after a first myocardial infarction. Interventions focusing on reducing stressors at the workplace or on improving coping with work stress in cardiac patients might improve their survival post-AMI.

Effort-reward imbalance at work and self-rated health of Las Vegas hotel room cleaners

BACKGROUND

This study investigates the relationship between effort-reward-imbalance (ERI) at work and self-rated health (SF-36) among 941 Las Vegas hotel room cleaners (99% female, 84% immigrant).

METHODS

Logistic regression models adjust for age, health behaviors, physical workload and other potential confounders.

RESULTS

50% reported ERI and 60% poor or fair general health. Significant associations were found between ERI and all SF-36 health measures. Workers in the upper quartile of the efforts/rewards ratio were 2-5 times more likely to experience poor or fair general health, low physical function, high levels of pain, fatigue, and role limitations due to physical and mental health problems.

CONCLUSIONS

The cross-sectional design limits causal interpretation of these associations. However, the development of interventions to reduce ERI and to improve general health among room cleaners deserves high priority considering that both high ERI and low self-rated health have predicted chronic diseases and mortality in prospective studies.

Validity and reliability of the effort-reward imbalance questionnaire in a sample of 673 Italian teachers

PURPOSE

This study explores the explicative potential of effort-reward imbalance Model to unveil the dimensions involved in teacher stress process and analyses the psychometric characteristics of the Italian version of the ERI Questionnaire (Siegrist, J Occup Health Psychol 1:27-43, 1996) with respect to a homogeneous occupational group: Italian school teachers.

METHODS

The Italian version of the ERI Questionnaire was submitted to 673 teachers randomly drawn from a cross-section of school types. Internal consistency, reliability, discriminative validity, and factorial structure were evaluated. Predictive validity was explored with respect to a measure of perceived strain, the Crown-Crisp Experiential Index. Discriminative validity was explored with respect to age, gender, education, type of school, the presence/absence of physical pains in the last 12 months before the survey, and teachers' intention to leave the profession.

RESULTS

Item-total correlations are for all items included between 0.30 and 0.80 (p < 0.01). Mean inter-item correlation is 0.26. Cronbach's alpha for the whole questionnaire reaches the value of 0.89. The factor analysis identified four reliable factors that accounted for 44.8 per cent of the total variance and which confirmed the basic structure emerged from previous studies yet highlighting two instead of three different components for reward. Higher efforts (T = -3.82, p < 0.001) and both lower material (T = 3.23, p < 0.001) and immaterial rewards (T = 3.17, p < 0.005) characterised the group of teachers, which reported to suffer for physical pains. Higher efforts (T = -5.26, p < 0.001), higher overcommitment (T = -3.15, p < 0.005), and both lower material (T = 4.63, p < 0.001) and immaterial rewards (T = 4.00, p < 0.001) were observed in the group of teachers inclined to give up the job. Multiple regression analyses have highlighted that higher efforts, higher overcommitment, and lower rewards are significantly predictive of higher levels of free-floating and somatic anxiety as well as depression and global psychological strain.

CONCLUSIONS

This preliminary analysis of the reliability and validity of the Italian version of the ERI Questionnaire reveals that it constitutes a useful and reliable measure to analyse work-related stress with respect to the school setting. The validity of the ERI model to describe the dimensions involved in teacher's stress and to highlight those associated to leaving intentions and to several physical and psychological strain outcomes in Italian school teachers has been confirmed.

Distribution of effort-reward imbalance in Denmark and its prospective association with a decline in self-rated health

OBJECTIVE

To analyze the distribution of effort-reward imbalance (ERI) and to investigate its impact on self-rated health in a representative sample of the Danish workforce.

METHODS

We studied 4977 employees who responded to a questionnaire in 2000, of which 3470 responded to a follow-up survey in 2005.

RESULTS

The highest (ie, most unfavorable) ERI ratio was found in executives in the public sector, social workers, managing clerks in the public sector, and medical secretaries. A one standard deviation increase of the ERI ratio predicted a 12% (95% confidence intervals = 1.01 to 1.24) decline in self-rated health after adjustment for all covariates.

CONCLUSIONS

This is the first study that identified job groups with a high exposure to ERI in a representative sample of a national workforce. ERI was a risk factor for a decline in self-rated health.

Organizational justice, psychological distress, and work engagement in Japanese workers

PURPOSE

To investigate the cross-sectional association between organizational justice (i.e., procedural justice and interactional justice) and psychological distress or work engagement, as well as the mediating roles of other job stressors (i.e., job demands and job control, or their combination, effort-reward imbalance [ERI], and worksite support).

METHODS

A total of 243 workers (185 males and 58 females) from a manufacturing factory in Japan were surveyed using a self-administered questionnaire including the Organizational Justice Questionnaire, Job Content Questionnaire, Effort-Reward Imbalance Questionnaire, K6 scale, Utrecht Work Engagement Scale, and other covariates. Multiple mediation analyses with the bootstrap technique were conducted.

RESULTS

In the bivariate analysis, procedural justice and interactional justice were significantly and negatively associated with psychological distress; they were significantly and positively associated with work engagement. In the mediation analysis, reward at work (or ERI) significantly mediated between procedural justice or interactional justice and psychological distress; worksite support significantly mediated between procedural justice or interactional justice and work engagement.

CONCLUSION

The effects of organizational justice on psychological distress seem to be mediated by reward at work (or ERI) while those regarding work engagement may be mediated by worksite support to a large extent, at least in Japanese workers.

Psychosocial working conditions and work-related stressors among UK veterinary surgeons

BACKGROUND

Anecdotally, veterinary surgeons report high levels of work-related stress.

AIMS

To investigate psychosocial working conditions, self-reported causes of work-related stress and satisfaction among a representative sample of vets practising in the UK.

METHODS

A cross-sectional study using a questionnaire mailed to a stratified random sample of 3200 vets. The Health & Safety Executive Management Standards Indicator Tool and a series of bespoke questions were embedded in a 120 item questionnaire, which also assessed anxiety and depressive symptoms, alcohol consumption, suicidal ideation, positive mental well-being and work-home interaction.

RESULTS

A total of 1796 useable questionnaires were returned (response rate 56%). Number of hours worked and making professional mistakes were the main reported contributors to stress. Good clinical outcomes and relationships with colleagues were the greatest sources of satisfaction. Anxiety and depressive symptoms are associated with less favourable working conditions.

CONCLUSIONS

Compared to the general population, the sample reported higher risk of work-related stress for demands and managerial support but lower risk for relationships and change. The results could be used to inform the development of targeted interventions.

Effort-reward imbalance at work and risk of sleep disturbances. Cross-sectional and prospective results from the Danish Work Environment Cohort Study

OBJECTIVES

This study aimed to analyze if adverse psychosocial working conditions, defined by the model of effort-reward imbalance (ERI), increase the risk of sleep disturbances in the Danish workforce.

METHODS

Analyses were conducted both cross-sectionally and prospectively in a representative sample of Danish employees. The cross-sectional sample included 2614 participants (50% women) aged 18-59 years, of whom 263 had sleep disturbances. Of the 2351 participants initially free of sleep disturbances, 304 (12.9%) developed sleep disturbances during the 5-year follow-up. Data were analyzed with gender-stratified, multivariate logistic and linear regression analyses, adjusted for numerous covariates.

RESULTS

Cross-sectionally, a 1 S.D. increase in the ERI ratio was associated with sleep disturbances among both men [odds ratio (OR)=1.65, 95% confidence interval (CI)=1.20-2.27] and women (OR=1.82, 95% CI=1.46-2.28). In the prospective analysis, a 1 S.D. increase of the ERI ratio at baseline predicted the onset of sleep disturbances among men (OR=1.39, 95% CI=1.03-1.87) but not among women (OR=0.97, 95% CI=0.76-1.24).

CONCLUSION

Among men, ERI is a risk factor for the development of sleep disturbances in the Danish workforce. Among women, an association between ERI and sleep disturbances was restricted to the cross-sectional sample. Improving psychosocial working conditions might reduce the risk of sleep disturbances and subsequently also help to prevent clinical disorders related to sleep disturbances.

Chronic psychosocial stress at work and risk of depression: evidence from prospective studies

Due to their high prevalence and severe consequences depressive disorders provide a primary challenge to medicine and public health. Improving our understanding of modifiable risk factors may help to advance preventive efforts. Chronic psychosocial stress at work, as defined by two theoretical models, demand-control and effort-reward imbalance, is one such modifiable risk factor. This paper reviews and discusses current evidence of associations between work-related psychosocial stress and depression based on a systematic review of prospective cohort studies of these two models, published within the last 10 years. Findings from 12 reports indicate a rather consistently elevated odds ratio of about 1.8 of depression among men and women who were exposed to high demand and low control at work or who spent high efforts in combination with low rewards received in turn. Findings are substantiated by results from experimental investigations that explored psychobiological mechanisms underlying this association. In conclusion, there is solid evidence of a prospectively established moderate association of chronic psychosocial stress at work, as defined by theoretical models, with depression. Despite open research questions the implications of these findings for prevention should be addressed.

[Psychosocial stress and disease risks in occupational life. Results of international studies on the demand-control and the effort-reward imbalance models]

Given the far-reaching changes of modern working life, psychosocial stress at work has received increased attention. Its influence on stress-related disease risks is analysed with the help of standardised measurements based on theoretical models. Two such models have gained special prominence in recent years, the demand-control model and the effort-reward imbalance model. The former model places its emphasis on a distinct combination of job characteristics, whereas the latter model's focus is on the imbalance between efforts spent and rewards received in turn. The predictive power of these models with respect to coronary or cardiovascular disease and depression was tested in a number of prospective epidemiological investigations. In summary, twofold elevated disease risks are observed. Effects on cardiovascular disease are particularly pronounced among men, whereas no gender differences are observed for depression. Additional evidence derived from experimental and ambulatory monitoring studies supplements this body of findings. Current scientific evidence justifies an increased awareness and assessment of these newly discovered occupational risks, in particular by occupational health professionals. Moreover, structural and interpersonal measures of stress prevention and health promotion at work are warranted, with special emphasis on gender differences.

Trends in self-reported sleep duration and insomnia-related symptoms in Finland from 1972 to 2005: a comparative review and re-analysis of Finnish population samples

A hypothesis concerning habitual sleep reduction and its adverse consequences among general population in modern societies has received wide publicity in the mass media, although scientific evidence supporting the hypothesis is scarce. Similarly, there is an extensively distributed belief, at least in Finland, that the prevalence of insomnia-related symptoms is increasing, but evidence for this is even sparser. These issues are important because of the known increased risk of mortality and health risks associated with sleep duration deviating from 7 to 8 h. To reveal possible trends in self-reported sleep duration and insomnia-related symptoms, we reanalyzed all available data from surveys carried out in Finland from 1972 to 2005. The main results were that a minor decrease of self-reported sleep duration has taken place in Finland, especially among working aged men. However, the size of the reduction (about 4%) was relatively small, approximately 5.5 min per each 10 years during the 33 years' time interval under study. The proportion of 7 h sleepers has increased and, correspondingly, the proportion of 8 h sleepers has decreased, but the extreme ends of the sleep duration distribution remained unchanged. Tentative evidence suggesting an increase in insomnia-related symptoms among working aged population during the last 10 years was found. In conclusion, the Finnish data during the past 33 years indicate a general decrease in self-reported sleep duration of about 18 min and an increase of sleep complaints, especially among the employed middle-aged population.

Work stress and reduced health in young physicians: prospective evidence from Swiss residents

OBJECTIVES

Job stress, investigated by the effort-reward model in various working environments in different countries, has been widely reported, yet studies addressing physicians are lacking. The present study investigated the perceived job stress, its association with the amount of working hours, and its impact on young physicians' self-reported health and their satisfaction with life during residency.

METHODS

In a prospective study design, a cohort of Swiss medical school graduates was followed up, beginning in 2001. In their second and fourth years of residency, 433 physicians assessed their effort-reward imbalance, overcommitment, physical and mental well-being and satisfaction in life. Taking the longitudinal design into account, four categories of stressed residents were defined: (1) subjects not reporting high work stress at either measurement, (2) subjects reporting high work stress in the second but not in the fourth year of residency, (3) subjects with onset of high work stress in fourth year and (4) residents reporting high work stress at both measurements.

RESULTS

All components of the perceived stress at work were significantly correlated with the amount of working hours, effort showing the highest correlation. While two-thirds of the participants do not report high work stress, assessed by the extrinsic part of the effort-reward imbalance model (the ratio between effort and reward) and 12% show a decrease of stress over time, there are 15% with an increase of stress over time, and 10% with persistently high stress experience. In terms of the intrinsic stress component (overcommitment), 71% show low values, 12% show a decrease, 9% an increase and 8% constantly high values. The groups with constant and increasing extrinsic and intrinsic stress experience exhibit significantly worse health and life satisfaction compared to the remaining groups, after controlling for gender and baseline health.

CONCLUSIONS

Stress at work in young physicians, especially when being experienced over a longer period in postgraduate training, has to be a matter of concern because of its negative impact on health and life satisfaction and the risk of developing symptoms of burnout in the long run.

Two models of job stress and depressive symptoms. Results from a population-based study

BACKGROUND

Evidence indicates that an adverse psychosocial work environment contributes to the explanation of depressive symptoms. Research was mainly informed by two theoretical models, the demand-control and the effort-reward imbalance model. Yet, a comparative analysis of the two models, using original scales, has not yet been conducted in an unselected working population.

METHODS

A total of 1,811 working men and women from the baseline screening of an epidemiological cohort study were interviewed (job stress, depressive symptoms [CES-D], health behaviours, medical history, socio-demographic characteristics). Logistic regression models were calculated to estimate associations between depressive symptoms, the two job stress models and relevant covariates.

RESULTS

Analyses showed significantly increased multivariate odds ratio (OR) of job strain and effort-reward imbalance. When the two models were mutually adjusted control [OR, 95% CI=1.9, 1.3-2.7], effort-reward imbalance [OR, 95% CI=3.4, 2.1-5.1] and overcommitment OR, 95% CI=3.9, 2.7-5.8] were independently associated with depressive symptoms Additional tests of interaction between the models revealed relatively highest level of depressive symptoms in employees who simultaneously reported low control and high overcommitment.

CONCLUSIONS

Components of an adverse psychosocial work environment are associated with depressive symptoms in an unselected working population. Policy implications of accumulated evidence on this relation should be addressed.

The impact of work environment on mood disorders and suicide: Evidence and implications

The purpose of this paper is to review the evidence estimating an impact of occupational factors on mood disorders and suicide, and the efficacy of interventions. This review is based on literature searches using Medline and Psych INFO from 1966 to 2007 (keywords: work stress, job insecurity, job strain, shift work, violence, occupational health, mood disorders, depression, and suicide). To establish the relationship between occupational variables and mood disorders, we focused on clinically significant disorders rather than depressive symptoms. During the last decade, prospective epidemiological studies have suggested a predictive association between the work environment and mood disorders. Recently, increasing numbers of clinical trials have shown favorable effect size of intervention and suggested preferable return-on-investment results. However, low awareness and social stigma still decrease workers access to treatment. Mental health professionals in conjunction with employers have to devise a creative system to make the quality care being offered more accessible to employees. In addition, further outcome data is needed to evaluate the benefit of managing mood disorders in the workplace, and to foster awareness of positive implications for employees, employers, their families, and the society at large. In addition, the work environment, with its chemical (e.g. chemosensory factors, pollutants), physical (e.g. lighting, noise, temperature, outdoor views and activities), biological (e.g., chronobiological factors, allergens, infectious agents), psychological (e.g. demand-control, effort-reward balance), social (e.g. cohesiveness, support), and organizational (e.g. leadership styles) component should meet minimal standards, and may improve with striving towards the optimum.