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Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Occupational Incidence Rates of Mental Health Disorders a
a
Dr. Michael J. Colligan Ph.D. , Dr. Michael J. Smith Ph.D. & Mr. Joseph J. Hurrell Jr. M.A.
a
a
Research Psychologists , National Institute for Occupational Safety and Health , Cincinnati, Ohio, 45226, USA Published online: 09 Jul 2010.
To cite this article: Dr. Michael J. Colligan Ph.D. , Dr. Michael J. Smith Ph.D. & Mr. Joseph J. Hurrell Jr. M.A. (1977) Occupational Incidence Rates of Mental Health Disorders, Journal of Human Stress, 3:3, 34-39, DOI: 10.1080/0097840X.1977.9936090 To link to this article: http://dx.doi.org/10.1080/0097840X.1977.9936090
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
OCCUPATIONAL INCIDENCE RATES OF MENTAL HEALTH DISORDERS
Downloaded by [New York University] at 10:13 21 February 2015
MICHAEL J. COLLIGAN, Ph.D.. MICHAEL J . SMITH, Ph.D., and JOSEPH J. HURRELL, JR., M.A.
This study attempted to provide occiipational health professionals with an empirical basis for identijjing and selecting specific occupations f o r further research into the relationship between j o b stress arid worker health. Specifically, this involved a n exutriiiiatioti of the udmissioti records of community mental health centers throiighout one state (Tennessee) to determine the incidence rute of dicrgnosed mental health disorders for 130 mqjor occupations (i.e . . occiipations emplo-ying 1,000 or more workers iti the state). These occupations were then rankordered bv incidence rute to provide a general scheme for evalirutitig the relative frequency of' mental heulth disorders uniotig the select occupations. The results indicuted u disproportionate incidence o f mental health anonialies umong the hospital/health care professions. Some tentative explunations of this .finding are presented. and suggestions ure made for jutitre research efforts.
The selection of specific occupations for intensive research into the relationship between psychological job stress and worker physical and mental health has been based largely upon the educated guesses and personal preferences of the research community. Air traffic controllers,' assembly-line and p ~ l i c e m e n ,for ~ example, have received considerable attention, more because of publicity concerning the various stresses associated with these jobs than because of any prior evidence of disproportionate morbidity among these workers. No objective criteria presently exist which would permit a comparison of these ocDr. Colligan, Dr. Smith and Mr. Hurrell are Research Psychologists at the National Institute for Occupatinnal Safety and Health in Cincinnati. Ohio 45226.
34 Journal of Human Stress
cupations with other job classifications in terms of inherent psychological job stress factors and/or their resultant health impact. It is therefore possible that other, less publicized, occupations expose workers to equivalent, or even more. psychological job stressors and health/strain consequences. Thus, the need arises for some means of rating or rank-ordering major occupations in terms of the degree of job stress and related health problems which they encompass. Given this ranking, health professionals could rationally choose priority occupations for study based on objective criteria such as the incidence and severity of psychological job stresdstrain problems and the size of the specific work force at risk. Once identified, September. 1977
COLLIGAN, SMITH, HURRELL various strategies and techniques could be developed for mitigating the health/strain effects of high stress occupations. Toward this end, the National Institute for Occupational Safety and Health (NIOSH) has sponsored an investigation to determine the relative incidence of: ( 1 ) mental health disorders, (2) health problems of a psychogenic nature, and (3) mortality from stress-induced or stressrelated disorders. The present paper describes the results of the mental health disorders phase of this study.
Downloaded by [New York University] at 10:13 21 February 2015
METHOD
Attention was focused on objective indices of mental health disorders as contrasted with selfreport or questionnaire measures. This involved an epidemiologic examination of mental health center records to determine the frequency of admission of individuals employed in major occupational categories. These frequencies were then related to population norms for each job classification (based on census data) to give an occupational incidence rate of mental health disorders. The major occupations were then rank-ordered in terms of decreasing rates of mental health center admissions to provide a systematized basis for establishing future research priorities. Mental Health Center Records
The data for this study were collected from the records of 22 of the 27 mental health centers operated by the State of Tennessee (the remaining five chose not to participate). These centers, located throughout the state, provide a full range of diagnostic and therapeutic outpatient services. All facilities used the DSM I1 (Diagnostic and Statistical Manual of Mental Disorders, 1968) standardized diagnostic format for classifying admission. The records of all first admissions to the 22 participating mental health centers from January, 1972, through June, 1974, were examined for their relevance to the present study. Several of the facilities had been in operation only since 1973. (In these centers data were gathered from whatever records were available from the time the centers opened through June, 1974.) The selection of actual cases for inclusion in
September, 1977
the sample was based on the following criteria: (1) the individual must have been a resident of Tennessee, in the primary working age group of 18-64, and (2) he/she must have been employed in one of the state’s major occupations within two years prior to admission. The purpose of limiting data collection to Tennessee residents was to allow for comparison of mental health within a defined work force and geographic area. Occupations
An occupation was considered major if it was found to employ 1,000 workers in the State of Tennessee in 1970. These employment figures were supplied by the State Department of Employment Security, based on data collected by the United States Bureau of Census. This source provided information on the frequency and demographic characteristics (age, sex, race, etc.) of workers in each occupational category in the state. Occupations were coded according to the system used by the Tennessee Employment Security Department in statistical reporting procedures. Descriptions of the various job titles generally correspond to those used in the Dictionary of Occupational Titles (DOT) (1965). and this source may be used to obtain a commentary of the activities associated with each occupational category. The initial list consisted of 190 occupations employing 1,000 or more individuals in the year 1970. As data collection began, however, it became apparent that in some cases the job descriptions contained on the mental health records were insufficient to allow for an accurate classification in terms of the DOT system. This necessitated a restructuring of the original list - essentially, a clustering of similar occupations. For example, mail carriers, mail handlers, and postal clerks were all treated as one occupational category. mail handlers. Similarly, bulldozer operators, cranemen, derrickmen, hoistmen, earth drillers, and excavating and grading operators were all classified into one category, heavy equipment operators. This clustering reduced the original list to 130 occupations and greatly simplified the classification process. InterJournal of Human Stress 35
Downloaded by [New York University] at 10:13 21 February 2015
JOB STRESS AND WORKER HEALTH rater reliability checks were obtained by having different raters independently classify the occupations of random groups of workers selected from the mental health center record files. Comparisons of these classifications showed greater than 90 percent agreement, which increased to more than 95 percent after additional training of the raters. The study involved examining all records from the 22 mental health centers from January, 1972 to June. 1974, and recording the frequency and diagnosis for all admissions meeting the occupational, age, and residency selection criteria. Diagnostic information. age. sex, and race for each case were recorded after removing all personal identifiers (e.g., names, social security numbers, etc.). Data were recorded for a total of 8,450 cases. RESULTS AND DISCUSSION Table 1 presents the characteristics of sex, age, and race for the mental health admissions and total work population based on the hospital records and the Bureau of Census data. I t can be seen that females were proportionally more likely than males to receive treatment from one of the mental health facilities since they comprised 53 percent of the admissions as compared to 39 percent of the working population. Males, on the other hand. comprised 47 percent of the admissions as compared to 61 percent of the working population. A chi-square analysis showed the difference between male and female admissions to be statistically significant ( x ' = 8.24. df 1 1 , p < .Ol), using expectancies based on Census norms. The distribution of races in the hospital records data was almost identical to that in the state population ( 1 1 percent vs. 13 percent black, respectively). The mean age of the patient group was 33 years as compared to 39 years in the working population. To rank-order the major occupations in terms of the relative incidence of mental disorders. two separate analyses were performed. The first involved computing the sample frequency of admissions for each occupation relative to the working population frequency of that occupation. The resultant score was then
36 Journal of Human Stress
multiplied by 1,000, resulting in mental health center admissions rates per 1.000 employees for each occupation. The second analysis involved the computation of z scores for each occupation, comparing the observed frequency of admissions per occupation in the sample with the expected frequency of that occupation in the sample, based on the population norms supplied by the Census data (1976). It was assumed that the relative frequency of a given occupation in the sample should not significantly exceed the relative frequency of that occupation in the population. Since the purpose of this study was to identify those occupations exhibiting a high incidence of mental disorders (and therefore positive z scores) a one-tailed test of significance was used (z >, 2.33. p < .01). Those occupations with significant z scores were considered to have a higher incidence of mental health problems than would be expected from population norms. Table 2 presents a rank-ordering. based on admission rates, of the 30 occupations with the highest incidence of mental health problems in the sample, along with their respective z scores. It can be seen from Table 2 that health technicians exhibited the highest incidence of mental disorder admissions, followed by waiters and waitresses, practical nurses, inspectors and musicians. The z scores tended to substantiate the rank-ordering based on incidence rates, as indicated by the fact that the top 24 occupations had a significantly higher than expected admission rate based on population norms (z 2 2.33, p < .01).* It is interesting to note that of the top 22 occupations, six are related to hospital/health care operations. These a r e : health technologists. practical nurses, clinical lab technicians, nurses' aides, health aides, and registered nurses. It may be that particular stressors present in the hospital environment are conducive to the development of mental disorders. Goffman,' has discussed the lack of *When taniple sizes a r e large a n d the test involves one degree of freedom, 7 is exactly equal to the square root of chi'. See A.E. Edwards. Stutisticul Methods .for rhr Rc,haiif,ru/Scie,icrs. p. 370. Rinehart. New York. 1954.
September, I977
COLLIGAN, SMITH, HURRELL
TABLE 1 MENTAL HEALTH ADMISSIONS BY SEX, RACE AND AGE FOR 18-64YEAR-OLDS % M.H. Admissions (n = 8,450)
% Employed Population* ( N = 1,345,610)
Male Female
47 53
61 39
White Black
89 11
87 13
Average Age
33 years
39 years
Downloaded by [New York University] at 10:13 21 February 2015
*Tennesseans employed in major occupations in 1970, ages 18-64.
TABLE 2 OCCUPATIONAL ADMISSION RATES AND 2 SCORES FOR MENTAL HEALTH ADMISSIONS ~
Rank
1 2 3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
20 21
22 23
24 25 26 27 28 29 30
~~
Code
Occuoation
Sample n
1098 7215 7136 5105 1134 1162 1034 7054 8216 7135 8113 7051 4219 1169 1040 1154 4205 7095 1149 7096 6198 1025 4009 1187 5171 4182 1137 6141 5007 5194
Health Technol. Tech. nec Waiters, Waitresses Practical Nurse LPN Inspectors Musician Public Relations Clinical Lab Tech. Dishwasher Warehousemen Nurses' Aides Laborers Dental Assistant Teacher Aide Research Worker Computer Programmer Photographer Telephone Operator Hairdresser Painters, Sculptors Health Aides Taxicab Drivers Chemist Bank Tellers Social Workers Roofers-Slaters Secretaries Nurses, Registered Operatives Bakers Struc. Metal Craftsmen
39 370 102 81 37 22 42 29 23 181 488 18 33 18 35 13 85 127 13 25 23 24 43 60 14 621 136 1291 14 38
z Score"' 11.39 27.42 13.34 11.43 7.32 5.22 6.11 4.99 4.50 11.60 18.89 3.29 4.56 3.29 4.41 2.91 6.59 8.02 2.40 3.12 3.25 3.18 3.74 4.31 1.91 13.27 5.87 18.50 1.54
2.73
Admission Rate" (per 1,OOO)
30.68 23.46 21.39 20.45 19.14 18.70 15.90 15.80 14.94 14.44 14.28 13.89 13.86 13.30 13.27 12.96 12.69 12.58 12.33 11.93 11.91 11.64 11.00 10.85 10.70 10.50 10.34 10.21 9.81 9.80
* For the entire sampling period of over t w o years (not annualized). **Underlined z scores are significant (z22.33, p d ,011, using a one-tailed test.
September. 1977
Journal of Human Stress 37
JOB STRESS AND WORKER HEALTH
TABLE 3 MENTAL HEALTH DIAGNOSES Percent of Sample ( n 8,450) % Females 7
% Males
Neuroses Personality disorders Psychoses Transient situational disturbances Social maladjustment Admin. deferred Alcoholism Drua deoendencv All h ;e; diagnoses
11
2 4 __
Downloaded by [New York University] at 10:13 21 February 2015
correspondence between the norms regulating interpersonal relations in the hospital setting and those operating in the “real world.” The responsibility of caring for and interacting with people who are ill or infirm can be emotionally demanding, subjecting the health professional to considerable stress. I t is possible that the role-stresses associated with the “stigma of being sick,” as described by Goffman, affect not only the patient but individuals occupying complementary roles, such as health-care workers. This interpretation must be treated cautiously. however. for it is also possible that the high incidence of mental health disorders among health-related professions reflects a sex sampling bias in the present data. I t should be recalled that women comprise 53 percent of all admissions as compared to only 39 percent of the total working population. The high proportion of females employed in the health-related categories. rather than the operation of occupational-specific stressors. may have inflated the incidence rankings of these occupations relative to the others included in the sample. It is also possible that women in general and health-related workers in particular are more likely to report mental health disorders than the general working population because of a heightened sensitivity to and acceptance of emotional disturbances. Likewise. the work environment of the health professionals. with its emphasis on physical and psychological health maintenance, may encourage earlier detection and reporting of mental disturbances than other occupations and work environments. Thus, the obtained
30 14 11 11 11 10 4 3
5
3 5 5 4
47
38 Journal of Human Stress
19 7
7 6
% Total
8
6 5 0 1
2
6
53
100
~
occupational rankings may be more reflective of occupational differences in reporting tendencies and accessibility to treatment than actual incidence of mental health disorders. Follow-up research examining the relationship between job stress and mental health must be designed to control for sex differences in the reporting and/or actual incidence of mental health disorders. Frequencies of specific mental health disorders were too small to permit an analysis of the distribution of diagnostic categories for each of the major occupations. The incidence rates of certain mental health disorders were therefore computed over the entire sample of job categories. Table 3 presents the distribution of specific mental health disorders for the combined 130 major occupations. Neurosis was the most frequent occurring disorder, accounting for 30 percent of all mental health center admissions. followed by personality disorders (14 percent) and psychosis ( 1 1 percent). Nineteen percent of all female admissions were diagnosed as neurotic, as compared to eleven percent of the male admissions. The difference between the number of males and females admitted for neurosis was highly significant (x* = 155, df = 1 , p < .001). CONCLUSIONS
The present study was intended to provide a basis for defining job situations posing health problems owing to their stressful demands. Such information could then be used in setting priorities for investigations aimed at identifying individual job stressors and for September. 1977
Downloaded by [New York University] at 10:13 21 February 2015
COLLIGAN. SMITH, HURRELL providing remedial program measures. The data have certain limitations and therefore must be interpreted with caution. For example, professional and white-collar workers probably are underrepresented in this sample, as they are more likely to seek treatment from privately operated therapeutic sources. Also, the data do not permit the conclusion that occupational differences in the incidence of mental health disorders are a function of job stress as opposed to other life stress events. Other characteristics associated with occupational level, such as socioeconomic status, age, level of education, etc., undoubtedly contribute to the observed results. Inferences regarding the causal direction of the relationship between occupation and incidence of mental health disorders are not justified by the present study design. It is impossible to determine whether specific stressors associated with the respective occupations adversely affect worker psychological adjustment, or if individuals with preexisting tendencies to mental health disorders seek out and select certain occupations. Nevertheless, it is felt that the present study provides a rational basis of identifying specific occupations warranting intensive study regarding job stress and mental health. For example, inspectors have received very little attention from occupational mental health researchers, and yet the data from this study indicate that they ranked fourth among the major occupations in terms of incidence of mental health disorders. Further research is needed to identify the relationship between stressors common to quality control inspectors - such as boredom, underutilization of abilities, concentration, etc. - and psychological adjustment. Similarly, public relations personnel (ranked sixth in Table 2) have been studied primarily in terms of psychosomatic reactions to job stress, such as the incidence rates of migraine headaches or ulceration. The present study indicates that they are also susceptible to mental health disorders, possibly as a result of the interpersonal conflicts inherent in their job roles. The disproportionate number of female workers, especially those in the health-related September, 1977
occupations, seeking treatment in the community mental health centers warrants further study. This finding may reflect the operation of traditional sex roles, in that women are permitted a much greater range of affective reactions than men.6. ' Sex-specific socialization experiences might differentially affect the actual incidence, recognition, or reporting of mental health disorders among employed men and women. The present study design does not permit an evaluation of these various alternatives. To better understand the impact of occupational stress upon female mental health, the National Institute for Occupational Safety and Health soon will be undertaking an extensive study of problems specific to women in the workplace. This will be an attempt to examine more precisely the relationship between job stress and physical and mental health among female workers.
Data used to prepare this paper were gathered under Contract No. CDC-99-7440. National Institute for Occupational Safety and Health. conducted by the Dede Wallace Center. Nashville. Tennessee. Dr. Wayne Richards was Principal Investigator.
INDEXTERMS occupational mental health, mental health, industrial mental health, mental disorders - occupational incidence of.
REFERENCES 1. Cobb. S., and R.M. Rose. "Hypertension.
Peptic Ulcer and Diabetes in Air Traffic Controllers." J.A.M.A.. Vol. 224. 1973. pp. 489-492. 2. Kornhauser. A. T h e Mental Health of the Industrial Worker: AN Anulpsis und Review. Wile?. New York. 1965.
3. Blauner. R. Alirnurion und Frwdom: Thc. F U ~ I ( J Y Worker and His Industry. University of Chicago Press, Chicago, 1964. 4. Kroes. W.B., B.L. Margolis, and J.J. Hurrell. "Job Stress in Policemen." J. Police Sci. Administrution. Vol. 2. 1974. pp. 145-155. 5 . Coffman. E. Asylums. Aldine, Bristol. England. 1962. 6. Jourard. S. The Trunsparent Sell: Van Nostrand Reinhold, New York. 1964. 7. Bern. S.L. "The Measurement of Psychological Androgyny." J. Consult. Clin. P.~ychol..Vol. 42. No. 2. 1974. pp. 155-lh2.
Journal of Human Stress 39
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Occupational Incidence Rates of Mental Health Disorders a
a
Dr. Michael J. Colligan Ph.D. , Dr. Michael J. Smith Ph.D. & Mr. Joseph J. Hurrell Jr. M.A.
a
a
Research Psychologists , National Institute for Occupational Safety and Health , Cincinnati, Ohio, 45226, USA Published online: 09 Jul 2010.
To cite this article: Dr. Michael J. Colligan Ph.D. , Dr. Michael J. Smith Ph.D. & Mr. Joseph J. Hurrell Jr. M.A. (1977) Occupational Incidence Rates of Mental Health Disorders, Journal of Human Stress, 3:3, 34-39, DOI: 10.1080/0097840X.1977.9936090 To link to this article: http://dx.doi.org/10.1080/0097840X.1977.9936090
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
OCCUPATIONAL INCIDENCE RATES OF MENTAL HEALTH DISORDERS
Downloaded by [New York University] at 10:13 21 February 2015
MICHAEL J. COLLIGAN, Ph.D.. MICHAEL J . SMITH, Ph.D., and JOSEPH J. HURRELL, JR., M.A.
This study attempted to provide occiipational health professionals with an empirical basis for identijjing and selecting specific occupations f o r further research into the relationship between j o b stress arid worker health. Specifically, this involved a n exutriiiiatioti of the udmissioti records of community mental health centers throiighout one state (Tennessee) to determine the incidence rute of dicrgnosed mental health disorders for 130 mqjor occupations (i.e . . occiipations emplo-ying 1,000 or more workers iti the state). These occupations were then rankordered bv incidence rute to provide a general scheme for evalirutitig the relative frequency of' mental heulth disorders uniotig the select occupations. The results indicuted u disproportionate incidence o f mental health anonialies umong the hospital/health care professions. Some tentative explunations of this .finding are presented. and suggestions ure made for jutitre research efforts.
The selection of specific occupations for intensive research into the relationship between psychological job stress and worker physical and mental health has been based largely upon the educated guesses and personal preferences of the research community. Air traffic controllers,' assembly-line and p ~ l i c e m e n ,for ~ example, have received considerable attention, more because of publicity concerning the various stresses associated with these jobs than because of any prior evidence of disproportionate morbidity among these workers. No objective criteria presently exist which would permit a comparison of these ocDr. Colligan, Dr. Smith and Mr. Hurrell are Research Psychologists at the National Institute for Occupatinnal Safety and Health in Cincinnati. Ohio 45226.
34 Journal of Human Stress
cupations with other job classifications in terms of inherent psychological job stress factors and/or their resultant health impact. It is therefore possible that other, less publicized, occupations expose workers to equivalent, or even more. psychological job stressors and health/strain consequences. Thus, the need arises for some means of rating or rank-ordering major occupations in terms of the degree of job stress and related health problems which they encompass. Given this ranking, health professionals could rationally choose priority occupations for study based on objective criteria such as the incidence and severity of psychological job stresdstrain problems and the size of the specific work force at risk. Once identified, September. 1977
COLLIGAN, SMITH, HURRELL various strategies and techniques could be developed for mitigating the health/strain effects of high stress occupations. Toward this end, the National Institute for Occupational Safety and Health (NIOSH) has sponsored an investigation to determine the relative incidence of: ( 1 ) mental health disorders, (2) health problems of a psychogenic nature, and (3) mortality from stress-induced or stressrelated disorders. The present paper describes the results of the mental health disorders phase of this study.
Downloaded by [New York University] at 10:13 21 February 2015
METHOD
Attention was focused on objective indices of mental health disorders as contrasted with selfreport or questionnaire measures. This involved an epidemiologic examination of mental health center records to determine the frequency of admission of individuals employed in major occupational categories. These frequencies were then related to population norms for each job classification (based on census data) to give an occupational incidence rate of mental health disorders. The major occupations were then rank-ordered in terms of decreasing rates of mental health center admissions to provide a systematized basis for establishing future research priorities. Mental Health Center Records
The data for this study were collected from the records of 22 of the 27 mental health centers operated by the State of Tennessee (the remaining five chose not to participate). These centers, located throughout the state, provide a full range of diagnostic and therapeutic outpatient services. All facilities used the DSM I1 (Diagnostic and Statistical Manual of Mental Disorders, 1968) standardized diagnostic format for classifying admission. The records of all first admissions to the 22 participating mental health centers from January, 1972, through June, 1974, were examined for their relevance to the present study. Several of the facilities had been in operation only since 1973. (In these centers data were gathered from whatever records were available from the time the centers opened through June, 1974.) The selection of actual cases for inclusion in
September, 1977
the sample was based on the following criteria: (1) the individual must have been a resident of Tennessee, in the primary working age group of 18-64, and (2) he/she must have been employed in one of the state’s major occupations within two years prior to admission. The purpose of limiting data collection to Tennessee residents was to allow for comparison of mental health within a defined work force and geographic area. Occupations
An occupation was considered major if it was found to employ 1,000 workers in the State of Tennessee in 1970. These employment figures were supplied by the State Department of Employment Security, based on data collected by the United States Bureau of Census. This source provided information on the frequency and demographic characteristics (age, sex, race, etc.) of workers in each occupational category in the state. Occupations were coded according to the system used by the Tennessee Employment Security Department in statistical reporting procedures. Descriptions of the various job titles generally correspond to those used in the Dictionary of Occupational Titles (DOT) (1965). and this source may be used to obtain a commentary of the activities associated with each occupational category. The initial list consisted of 190 occupations employing 1,000 or more individuals in the year 1970. As data collection began, however, it became apparent that in some cases the job descriptions contained on the mental health records were insufficient to allow for an accurate classification in terms of the DOT system. This necessitated a restructuring of the original list - essentially, a clustering of similar occupations. For example, mail carriers, mail handlers, and postal clerks were all treated as one occupational category. mail handlers. Similarly, bulldozer operators, cranemen, derrickmen, hoistmen, earth drillers, and excavating and grading operators were all classified into one category, heavy equipment operators. This clustering reduced the original list to 130 occupations and greatly simplified the classification process. InterJournal of Human Stress 35
Downloaded by [New York University] at 10:13 21 February 2015
JOB STRESS AND WORKER HEALTH rater reliability checks were obtained by having different raters independently classify the occupations of random groups of workers selected from the mental health center record files. Comparisons of these classifications showed greater than 90 percent agreement, which increased to more than 95 percent after additional training of the raters. The study involved examining all records from the 22 mental health centers from January, 1972 to June. 1974, and recording the frequency and diagnosis for all admissions meeting the occupational, age, and residency selection criteria. Diagnostic information. age. sex, and race for each case were recorded after removing all personal identifiers (e.g., names, social security numbers, etc.). Data were recorded for a total of 8,450 cases. RESULTS AND DISCUSSION Table 1 presents the characteristics of sex, age, and race for the mental health admissions and total work population based on the hospital records and the Bureau of Census data. I t can be seen that females were proportionally more likely than males to receive treatment from one of the mental health facilities since they comprised 53 percent of the admissions as compared to 39 percent of the working population. Males, on the other hand. comprised 47 percent of the admissions as compared to 61 percent of the working population. A chi-square analysis showed the difference between male and female admissions to be statistically significant ( x ' = 8.24. df 1 1 , p < .Ol), using expectancies based on Census norms. The distribution of races in the hospital records data was almost identical to that in the state population ( 1 1 percent vs. 13 percent black, respectively). The mean age of the patient group was 33 years as compared to 39 years in the working population. To rank-order the major occupations in terms of the relative incidence of mental disorders. two separate analyses were performed. The first involved computing the sample frequency of admissions for each occupation relative to the working population frequency of that occupation. The resultant score was then
36 Journal of Human Stress
multiplied by 1,000, resulting in mental health center admissions rates per 1.000 employees for each occupation. The second analysis involved the computation of z scores for each occupation, comparing the observed frequency of admissions per occupation in the sample with the expected frequency of that occupation in the sample, based on the population norms supplied by the Census data (1976). It was assumed that the relative frequency of a given occupation in the sample should not significantly exceed the relative frequency of that occupation in the population. Since the purpose of this study was to identify those occupations exhibiting a high incidence of mental disorders (and therefore positive z scores) a one-tailed test of significance was used (z >, 2.33. p < .01). Those occupations with significant z scores were considered to have a higher incidence of mental health problems than would be expected from population norms. Table 2 presents a rank-ordering. based on admission rates, of the 30 occupations with the highest incidence of mental health problems in the sample, along with their respective z scores. It can be seen from Table 2 that health technicians exhibited the highest incidence of mental disorder admissions, followed by waiters and waitresses, practical nurses, inspectors and musicians. The z scores tended to substantiate the rank-ordering based on incidence rates, as indicated by the fact that the top 24 occupations had a significantly higher than expected admission rate based on population norms (z 2 2.33, p < .01).* It is interesting to note that of the top 22 occupations, six are related to hospital/health care operations. These a r e : health technologists. practical nurses, clinical lab technicians, nurses' aides, health aides, and registered nurses. It may be that particular stressors present in the hospital environment are conducive to the development of mental disorders. Goffman,' has discussed the lack of *When taniple sizes a r e large a n d the test involves one degree of freedom, 7 is exactly equal to the square root of chi'. See A.E. Edwards. Stutisticul Methods .for rhr Rc,haiif,ru/Scie,icrs. p. 370. Rinehart. New York. 1954.
September, I977
COLLIGAN, SMITH, HURRELL
TABLE 1 MENTAL HEALTH ADMISSIONS BY SEX, RACE AND AGE FOR 18-64YEAR-OLDS % M.H. Admissions (n = 8,450)
% Employed Population* ( N = 1,345,610)
Male Female
47 53
61 39
White Black
89 11
87 13
Average Age
33 years
39 years
Downloaded by [New York University] at 10:13 21 February 2015
*Tennesseans employed in major occupations in 1970, ages 18-64.
TABLE 2 OCCUPATIONAL ADMISSION RATES AND 2 SCORES FOR MENTAL HEALTH ADMISSIONS ~
Rank
1 2 3
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
20 21
22 23
24 25 26 27 28 29 30
~~
Code
Occuoation
Sample n
1098 7215 7136 5105 1134 1162 1034 7054 8216 7135 8113 7051 4219 1169 1040 1154 4205 7095 1149 7096 6198 1025 4009 1187 5171 4182 1137 6141 5007 5194
Health Technol. Tech. nec Waiters, Waitresses Practical Nurse LPN Inspectors Musician Public Relations Clinical Lab Tech. Dishwasher Warehousemen Nurses' Aides Laborers Dental Assistant Teacher Aide Research Worker Computer Programmer Photographer Telephone Operator Hairdresser Painters, Sculptors Health Aides Taxicab Drivers Chemist Bank Tellers Social Workers Roofers-Slaters Secretaries Nurses, Registered Operatives Bakers Struc. Metal Craftsmen
39 370 102 81 37 22 42 29 23 181 488 18 33 18 35 13 85 127 13 25 23 24 43 60 14 621 136 1291 14 38
z Score"' 11.39 27.42 13.34 11.43 7.32 5.22 6.11 4.99 4.50 11.60 18.89 3.29 4.56 3.29 4.41 2.91 6.59 8.02 2.40 3.12 3.25 3.18 3.74 4.31 1.91 13.27 5.87 18.50 1.54
2.73
Admission Rate" (per 1,OOO)
30.68 23.46 21.39 20.45 19.14 18.70 15.90 15.80 14.94 14.44 14.28 13.89 13.86 13.30 13.27 12.96 12.69 12.58 12.33 11.93 11.91 11.64 11.00 10.85 10.70 10.50 10.34 10.21 9.81 9.80
* For the entire sampling period of over t w o years (not annualized). **Underlined z scores are significant (z22.33, p d ,011, using a one-tailed test.
September. 1977
Journal of Human Stress 37
JOB STRESS AND WORKER HEALTH
TABLE 3 MENTAL HEALTH DIAGNOSES Percent of Sample ( n 8,450) % Females 7
% Males
Neuroses Personality disorders Psychoses Transient situational disturbances Social maladjustment Admin. deferred Alcoholism Drua deoendencv All h ;e; diagnoses
11
2 4 __
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correspondence between the norms regulating interpersonal relations in the hospital setting and those operating in the “real world.” The responsibility of caring for and interacting with people who are ill or infirm can be emotionally demanding, subjecting the health professional to considerable stress. I t is possible that the role-stresses associated with the “stigma of being sick,” as described by Goffman, affect not only the patient but individuals occupying complementary roles, such as health-care workers. This interpretation must be treated cautiously. however. for it is also possible that the high incidence of mental health disorders among health-related professions reflects a sex sampling bias in the present data. I t should be recalled that women comprise 53 percent of all admissions as compared to only 39 percent of the total working population. The high proportion of females employed in the health-related categories. rather than the operation of occupational-specific stressors. may have inflated the incidence rankings of these occupations relative to the others included in the sample. It is also possible that women in general and health-related workers in particular are more likely to report mental health disorders than the general working population because of a heightened sensitivity to and acceptance of emotional disturbances. Likewise. the work environment of the health professionals. with its emphasis on physical and psychological health maintenance, may encourage earlier detection and reporting of mental disturbances than other occupations and work environments. Thus, the obtained
30 14 11 11 11 10 4 3
5
3 5 5 4
47
38 Journal of Human Stress
19 7
7 6
% Total
8
6 5 0 1
2
6
53
100
~
occupational rankings may be more reflective of occupational differences in reporting tendencies and accessibility to treatment than actual incidence of mental health disorders. Follow-up research examining the relationship between job stress and mental health must be designed to control for sex differences in the reporting and/or actual incidence of mental health disorders. Frequencies of specific mental health disorders were too small to permit an analysis of the distribution of diagnostic categories for each of the major occupations. The incidence rates of certain mental health disorders were therefore computed over the entire sample of job categories. Table 3 presents the distribution of specific mental health disorders for the combined 130 major occupations. Neurosis was the most frequent occurring disorder, accounting for 30 percent of all mental health center admissions. followed by personality disorders (14 percent) and psychosis ( 1 1 percent). Nineteen percent of all female admissions were diagnosed as neurotic, as compared to eleven percent of the male admissions. The difference between the number of males and females admitted for neurosis was highly significant (x* = 155, df = 1 , p < .001). CONCLUSIONS
The present study was intended to provide a basis for defining job situations posing health problems owing to their stressful demands. Such information could then be used in setting priorities for investigations aimed at identifying individual job stressors and for September. 1977
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COLLIGAN. SMITH, HURRELL providing remedial program measures. The data have certain limitations and therefore must be interpreted with caution. For example, professional and white-collar workers probably are underrepresented in this sample, as they are more likely to seek treatment from privately operated therapeutic sources. Also, the data do not permit the conclusion that occupational differences in the incidence of mental health disorders are a function of job stress as opposed to other life stress events. Other characteristics associated with occupational level, such as socioeconomic status, age, level of education, etc., undoubtedly contribute to the observed results. Inferences regarding the causal direction of the relationship between occupation and incidence of mental health disorders are not justified by the present study design. It is impossible to determine whether specific stressors associated with the respective occupations adversely affect worker psychological adjustment, or if individuals with preexisting tendencies to mental health disorders seek out and select certain occupations. Nevertheless, it is felt that the present study provides a rational basis of identifying specific occupations warranting intensive study regarding job stress and mental health. For example, inspectors have received very little attention from occupational mental health researchers, and yet the data from this study indicate that they ranked fourth among the major occupations in terms of incidence of mental health disorders. Further research is needed to identify the relationship between stressors common to quality control inspectors - such as boredom, underutilization of abilities, concentration, etc. - and psychological adjustment. Similarly, public relations personnel (ranked sixth in Table 2) have been studied primarily in terms of psychosomatic reactions to job stress, such as the incidence rates of migraine headaches or ulceration. The present study indicates that they are also susceptible to mental health disorders, possibly as a result of the interpersonal conflicts inherent in their job roles. The disproportionate number of female workers, especially those in the health-related September, 1977
occupations, seeking treatment in the community mental health centers warrants further study. This finding may reflect the operation of traditional sex roles, in that women are permitted a much greater range of affective reactions than men.6. ' Sex-specific socialization experiences might differentially affect the actual incidence, recognition, or reporting of mental health disorders among employed men and women. The present study design does not permit an evaluation of these various alternatives. To better understand the impact of occupational stress upon female mental health, the National Institute for Occupational Safety and Health soon will be undertaking an extensive study of problems specific to women in the workplace. This will be an attempt to examine more precisely the relationship between job stress and physical and mental health among female workers.
Data used to prepare this paper were gathered under Contract No. CDC-99-7440. National Institute for Occupational Safety and Health. conducted by the Dede Wallace Center. Nashville. Tennessee. Dr. Wayne Richards was Principal Investigator.
INDEXTERMS occupational mental health, mental health, industrial mental health, mental disorders - occupational incidence of.
REFERENCES 1. Cobb. S., and R.M. Rose. "Hypertension.
Peptic Ulcer and Diabetes in Air Traffic Controllers." J.A.M.A.. Vol. 224. 1973. pp. 489-492. 2. Kornhauser. A. T h e Mental Health of the Industrial Worker: AN Anulpsis und Review. Wile?. New York. 1965.
3. Blauner. R. Alirnurion und Frwdom: Thc. F U ~ I ( J Y Worker and His Industry. University of Chicago Press, Chicago, 1964. 4. Kroes. W.B., B.L. Margolis, and J.J. Hurrell. "Job Stress in Policemen." J. Police Sci. Administrution. Vol. 2. 1974. pp. 145-155. 5 . Coffman. E. Asylums. Aldine, Bristol. England. 1962. 6. Jourard. S. The Trunsparent Sell: Van Nostrand Reinhold, New York. 1964. 7. Bern. S.L. "The Measurement of Psychological Androgyny." J. Consult. Clin. P.~ychol..Vol. 42. No. 2. 1974. pp. 155-lh2.
Journal of Human Stress 39
