Pre-deployment stress briefing: does it have an effect?

BACKGROUND: The role of giving information about stress and stress reactions to people about to be exposed to hazardous situations remains unclear. Such information might improve coping and hence resilience. Alternatively, it might increase the expectancy of experiencing adverse psychological consequences following exposure to a hazard. AIM: To determine the effect of a pre-operational stress briefing on health and occupational indices among Naval and Marine personnel who were subsequently deployed to the 2003 Iraq War. METHOD: Controlled, non-randomized, parallel group study. Mental health outcomes post-deployment were compared between those who received a pre-operational stress briefing and those who did not receive such a briefing. RESULTS: Stress briefing attendees were slightly younger, more likely to be marines and to have been exposed to traumatic events than non-attendees. There were no significant differences between the two groups for the health outcomes of common mental health disorders, post-traumatic stress disorder or alcohol misuse. Attendees reported higher morale/cohesion but these differences disappeared following adjustment for demographic and military factors. No differences between the two groups were apparent for experiencing problems during or post-deployment or for marital satisfaction. CONCLUSIONS: We found no evidence that a pre-deployment stress briefing reduced subsequent medium-term psychological distress. On the other hand, we found no evidence of harm either. While only a randomized trial can give genuinely unbiased results, at present stress debriefing must be regarded as an unproven intervention, and it remains a matter of judgement as to whether or not it is indicated.     

Post-traumatic stress disorder in occupational settings: anticipating and managing the risk

BACKGROUND: Post-traumatic stress disorder has had a substantial impact on employer liability for workplace psychological injury. The emergency services are an example of high-risk workforces that demand clear policies and procedures within an organization. The challenge is to minimize the injury to individuals and lessen the cost to organizations through the optimal application of preventative strategies. METHODS: This field is not well represented in standard keyword searches and Medline was examined with linked fields of practice and research. Consensus guidelines that refer to this domain were also utilized. Few conclusions can be reached from the literature which directly examined occupational settings. RESULTS: Organizations need to anticipate the possible traumatic exposures that may affect the workforce and have strategies to deal with the effects in the workplace, particularly the negative mental health outcomes in some personnel. This domain is relevant to all employers as accidents and violence are possible in most workplaces. Screening should be considered for high-risk individuals, particularly following a major traumatic event or cumulative exposure, such as in the emergency services. While psychological debriefing has no demonstrated benefit, the benefits of early intervention necessitate ready access to evidence-based treatments that have minimum barriers to care. Employers should be aware that distress may present indirectly in a similar way as conflict with management, poor performance and poor general health. CONCLUSION: The knowledge about the impact of traumatic events obliges employers to have an active strategy to anticipate and manage the aftermath of such events as well as cumulative traumatic exposures.     

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an increasingly recognized and potentially preventable condition. Certain factors, especially the severity of the trauma, perceived lack of social support and peri-traumatic dissociation have been associated with its development. In recent years, a more robust evidence base regarding the management of individuals involved in traumatic events has emerged. Immediately after a traumatic event, simple practical, pragmatic support provided in a sympathetic manner by non-mental health professionals seems most likely to help. For individuals who develop persisting PTSD, trauma-focused cognitive behavioural therapy (TFCBT) may be beneficial within a few months of the trauma. For those who develop chronic PTSD, TFCBT and eye movement desensitization and reprocessing are best supported by the current evidence. Some anti-depressants appear to have a modest beneficial effect and are recommended as a second-line treatment. The current evidence base has allowed the development of guidelines that now require implementation. This has major implications in terms of planning and developing services that allow appropriately qualified and trained individuals to be available to cater adequately for the needs of survivors of traumatic events.     

Work-related life events, psychological well-being and cardiovascular risk factors in male Swedish automotive workers

AIMS: To analyse the relationship between life events, social support, psychological well-being and cardiovascular risk factors in blue- and white-collar Swedish automotive workers. METHODS: Baseline questionnaire regarding life events, social support, depressed mood and mental strain and smoking habits. Follow-up questionnaire after 5 years included the Psychological General Well-being Inventory to assess various health variables. At baseline and follow-up, anthropometric data were obtained. Blood pressure, blood glucose and serum lipids were measured and smoking habits were surveyed. RESULTS: The blue-collar workers showed a profile indicating increased cardiovascular risk with a higher proportion of smokers, a higher waist to hip ratio and higher triglycerides. They also reported themselves to have worse general health and less emotional self-control, but were less anxious than the white-collar workers. Negative life events, especially those related to work seemed to affect the well-being of the blue-collar workers more adversely than the white-collar workers. Being nervous and depressed at baseline increased the risk of poor psychological well-being at the follow-up. Social support within this 5-year perspective was a factor which predicted psychological well-being in both worker categories. Increase in cholesterol/high-density lipoprotein-cholesterol (HDL-C) ratio was the only cardiovascular risk factor associated with the strain of life events but not with work-related events. CONCLUSION: Over a 5-year period, men who experienced negative, strongly stressful and work-related life events displayed poorer psychological well-being at follow-up regardless of worker category. Social support was protective.     

An evaluation of stress education in the Royal Navy

Background Psychoeducational programmes aim to reduce the morbidityassociated with exposure to stressful events. Although theyare widely used, there are conflicting views as to how or whythey might be effective. Aim To examine exposure to ‘stress’ education withinthe Royal Navy (RN) and ascertain any links between stress educationand mental health status. Methods In all, 1559 RN personnel were surveyed using a studyquestionnaire which asked about exposure to and quality of anystress education provided during service. Participants alsocompleted two measures of psychological health, the GeneralHealth Questionnaire (GHQ)-12 item and the Post-Traumatic StressDisorder Checklist. Odds ratios (ORs) were calculated and 95%confidence intervals were computed using multivariable logisticregression adjusting for socio-demographic variables. Results The response rate was 70%; 47% of the sample reportedhaving received a stress brief during service. Those who reportedhaving received a brief had better general mental health (measuredby the GHQ) than those who had not [adjusted, OR = 0.76 (0.59–0.98)].When brief quality was taken into account, only those who receiveda brief and considered it ‘useful’ were significantlyless distressed [adjusted, OR = 0.65 (0.49–0.86)]. Poor-qualitybriefs were no better than having had no brief at all [adjusted,OR = 1.04 (0.74–1.47)]. Conclusions Our data indicate that only educational stress briefswhich are relevant for the target audience may be beneficial.Simply providing stress briefings, without thought to theirquality, may constitute a waste of resources.     

Post-trauma support in the workplace: the current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK

Employers' duties of care under both common and statute law include the need to take reasonable care of the health and safety of the workforce. This includes both the moral and legal duties to consider the psychological needs of personnel following exposure to traumatic events related to the workplace. While this has been recognized within many high-risk occupations such the police, fire and rescue services and the military, there is also evidence that post-trauma support in the workplace is increasingly commonly provided not only among health and social services agencies, but within many private sector organizations. Over the past decade, however, there has been considerable controversy over the provision of early psychological support to personnel in the form of critical incident stress management (CISM) processes. In particular, one aspect of CISM, the use of psychological debriefing (PD) has come under scrutiny and criticism as two studies indicated that PD was ineffective and had the potential to do harm. Inevitably, this has provoked much uncertainty and confusion among some organizations as what should be the most appropriate support. It has also led to misconceptions and misunderstandings as to the aims and purpose of PD, together with inaccuracies of terminology, for example describing PD as 'counselling'. Despite the controversy, both CISM and PD continue to be provided on a widespread basis, often utilizing a framework of voluntary peer group support. This paper intends to (i) present a review of the current status of CISM practices, including the use of PD within various organizations in the UK and (ii) provide a clear framework and understanding of the main issues and to clarify conceptual misunderstandings. The history, principles and background of the use of post-trauma support in the workplace, charting trends over the past two decades, previous research, problems with the evidence base and current thinking and practice in the field are reviewed. The relevance and implications of the National Institute for Clinical Excellence Guidelines on the Assessment and Management of Post Traumatic Stress Disorder, which make recommendations for early interventions for post-traumatic stress disorder are discussed. Reference is made to the use of CISM and PD within both statutory and voluntary organizations in an international context.     

Social and psychological resources and health outcomes after the World Trade Center disaster

Previous studies on community disasters tend to assess non-representative samples and use nonstandard measures of well-being. Additionally, few of these studies are longitudinal in design. In this report, we examine the consequences of the World Trade Center Disaster (WTCD) within a stress model perspective to assess level of exposure to the disaster and well-being after this event, as measured by the SF12 mental health and physical health scales. Data come from a two-wave panel study of 1681 English or Spanish speaking adults living in New York City on the day of the terrorist attacks and were collected by telephone interviews 1 and 2 years after the disaster. In ordinary least-squares regression models that contained demographic characteristics, stress risk factors, and social psychological resources as independent variables, level of exposure to the disaster was associated with poorer Wave 2 physical well-being, but not psychological health. Level of disaster exposure was not related to Wave 2 physical health, however, once the Wave 1 level of physical health was controlled, suggesting that disaster exposure did not have a lasting impact on variation in physical well-being. Results also indicated that experiencing a panic attack, negative life events, or traumatic events were related to poorer physical health. Respondents who met screening criteria for possible alcohol dependence post-disaster, experienced negative life events, or experienced traumatic events, were more likely to suffer from poorer mental health compared to those who did not meet the criteria, experience negative life events or experience traumas. We discuss these findings relative to community disasters in industrialized and developing countries.     

Morbidity in expatriates--a prospective cohort study

BACKGROUND: Expatriates comprise an important, but rarely studied subset of international travellers. This study was performed to assess the incidence of health events in an expatriate group and to evaluate factors affecting this incidence. METHODS: A cohort of 2020 Foreign and Commonwealth Office (FCO) staff and partners living abroad were followed-up over 1 year. The main outcome measure was incidence of illness or injury serious enough to require consultation with a doctor. Data collection was by means of a self-administered questionnaire. Poisson regression was used to estimate the rates of health events and to test for association between health events and a number of independent variables. RESULTS: The incidence of health events was 21%. Trauma (incidence 5%), musculoskeletal disorders (incidence 4%) and infectious disease (incidence 3%) were the principal causes of morbidity. The incidence of psychological disorders was low (1%). Of significance, employees were at increased risk of morbidity when compared to partners, with a higher incidence of health events [incidence rate ratio (IRR) 1.4, 95% CI 1.1-1.9] and psychological disorders (IRR 5.9, 95% CI 1.0-34.1). Moreover, unaccompanied employees were at increased risk of health events (IRR 1.3, 95% CI 1.0-1.7), and of traumatic injury (IRR 2.3, 95% CI 1.3-4.3) when compared to accompanied employees. CONCLUSION: While the morbidity in FCO personnel is low in comparison to other expatriate groups, the higher risk of morbidity in employees and unaccompanied individuals merits further research, particularly to ascertain whether work demands, isolation or risk-taking behaviour are contributory factors.     

Impact of trauma and torture on asylum-seekers

Background: Because most asylum seekers come from regions inwhich war and human rights violations are common, a systematicinvestigation of exposure to traumatic events and their psychologicalimpact was conducted. Methods: Over an eight month period, 573asylum-seekers were Interviewed shortly after arrival In Geneva,Switzerland, using a questionnaire to collect information onphysical and psychological symptoms and previous exposure totraumatic events. Results: Sixty-two per cent reported exposureto one or more traumatic events, and 18% reported having beentortured. Overall, 37% reported at least one severe symptomduring the previous week, most often of a psychological nature,such as sadness most of the time, insomnia, and anxiety. Personswho reported torture were more symptomatic than those who didnot, and symptoms were consistent with diagnoses of depressionand post-traumatic stress disorder. A follow-up visit was proposedto 28% of the entire sample, and to two thirds of those whoreported torture. Conclusion: These findings suggest that asimple checklist such as the one used in this study may assisthealth professionals to identify asylum seekers In need of furtherassessment and care to reduce long-term post-traumatic psycho-socialdisability and strengthen coping capability.     

Ergonomic methods for assessing exposure to risk factors for work-related musculoskeletal disorders

BACKGROUND: This review provides an overview of the range of methods that have been developed for the assessment of exposure to risk factors for work-related musculoskeletal disorders. METHODS: Relevant publications and material on exposure assessment techniques have been gathered for inclusion in this review. RESULTS: The methods have been categorized under three main headings: (1) self-reports from workers can be used to collect data on workplace exposure to both physical and psychosocial factors by using methods that include worker diaries, interviews and questionnaires; (2) observational methods that may be further subdivided between (a) simpler techniques developed for systematically recording workplace exposure that enable an observer to assess and record data on a number of factors using specifically designed pro-forma sheets for establishing priorities for workplace intervention; and (b) advanced techniques developed for the assessment of postural variation for highly dynamic activities that record data either on videotape or are computer analysed using dedicated software; (3) direct measurements using monitoring instruments that rely on sensors attached directly to the subject for the measurement of exposure variables at work. CONCLUSIONS: The choice between the methods available will depend upon the application concerned and the objectives of the study. General, observation-based assessments appear to provide the levels of costs, capacity, versatility, generality and exactness best matched to the needs of occupational safety and health practitioners (or those from related professions) who have limited time and resources at their disposal and need a basis for establishing priorities for intervention.     

Aggression in boat builders: a search for altered mood states in boat builders exposed to styrene

Published reviews and industrywide anecdotal reports have suggested an association between exposure to some volatile organic compounds (VOCs) and altered mood states. In this paper we report a unique study of boat-builders exposed to styrene. Two hundred and thirteen employees exposed to solvents and 144 who were not exposed completed questionnaires related to mood states. Additionally, for 23 of the 213 employees, the air concentrations of styrene were measured at their workplaces, and urinary concentrations of mandelic acid (a metabolite of styrene) were determined in order to assess biological exposure. Special features of this study included the use of the Prolife of Mood States (POMS) questionnaire and the availability of sound historical data. A weak association is demonstrated between styrene exposure and aggression/hostility. That this is found to be most marked in the earliest years of exposure suggests that selection characteristics might be a more important association than solvent exposure.     

Racial discrimination, ethnicity and work stress

BACKGROUND: Previous research has suggested higher work stress among minority ethnic workers. AIMS: To determine levels of work stress in three ethnic groups, consider the contribution of racial discrimination to the groups' profiles of occupational and demographic associations with stress, and assess the association between work stress and well-being. METHODS: A household quota sample design was used, and 204 black African-Caribbean, 206 Bangladeshi and 216 white (UK born) working people took part in structured interviews. RESULTS: More black African-Caribbean respondents reported high work stress than either Bangladeshi or white respondents. Reported racial discrimination among black African-Caribbean female respondents was strongly associated with perceived work stress. Among the black African-Caribbean respondents, women who reported experiencing racial discrimination at work had higher levels of psychological distress. CONCLUSIONS: Perceived work stress may be underpinned by exposure to racial discrimination at work among black African-Caribbean women, and this may affect their psychological well-being.     

Major chemical incidents: bridging the occupational--public health gap

Increasing awareness and concern about possible long-term health effects of exposure to chemicals after major chemical incidents has opened up a new area of public health activity. However, progress is hampered by a lack of low level exposures in potentially highly susceptible subgroups of the populations, and by a lack of expertise in public health. The challenge is to extend the toxicological and epidemiological experience developed in the occupational setting to the community level. To better define the problem population surveillance of acute chemical hazards, first set up in Wales, has been extended throughout the UK, and is also being piloted internationally. Further work is needed to address specific problems of the epidemiological follow-up of populations exposed, the assessment of the psychological consequences at the community level, and risk perception and communication. Organisational arrangements for the public health management of incidents and their sequelae must move beyond short-term funding and market competition and must incorporate the expertise of the occupational disciplines.     

Mental Health Problems in Separated Refugee Adolescents

PurposeAs migration and separation from parents are widely recognized as important risk factors for the mental health of adolescents, this study aims to investigate mental health problems in refugee adolescents separated from their parents compared to their accompanied peers, all living in Belgium.MethodsOne thousand two hundred ninety-four adolescents—10% of them refugee adolescents separated from both parents—completed three self-report questionnaires (Hopkins Symptoms Checklist-37A, Stressful Life Events, and Reaction of Adolescents to Traumatic Stress) on the prevalence of traumatic experiences, anxiety, and depression symptoms, externalizing problems, and posttraumatic stress.ResultsRefugee adolescents separated from both parents experienced the highest number of traumatic events compared to accompanied refugee adolescents. Risk factors influencing the development of serious mental health problems (anxiety, depression, and posttraumatic stress) are separation from parents, high number of traumatizing events experienced, and gender. Despite the fact that refugee adolescents living only with their mother experienced more traumatizing events compared to adolescents living with both parents, they have fewer mental health problems than refugee adolescents living with their father.ConclusionsThis study confirms the importance of the availability of parents to adolescents who have to deal with migration experiences, because separated refugee adolescents are at higher risk to experience multiple traumatic experiences and to develop severe mental health problems. Reception and care structures should provide more adequate preventive and curative interventions to these at-risk groups, and government policies should consider these adolescents primarily as “minors” rather than just “refugees.”     

Occupational asthma prevention and management in industry--an example of a global programme

Isocyanates are widely used in the manufacture of polyurethane foams, plastics, coatings and adhesives, and are known to cause occupational asthma in a proportion of exposed workers. Substitution as a prevention strategy is not currently a feasible option. For this reason, health and safety professionals working together in an automotive coatings business created a proactive global programme to address the known potential effects of isocyanates on its workers. The goals of the programme are prevention, early detection and mitigation of effect of key endpoints, especially asthma and to a lesser degree dermatitis, in people who are occupationally exposed, or potentially exposed, to isocyanates and products containing isocyanates. The surveillance programme for isocyanates has several important components, which include assessment of exposure, pre-placement questionnaire and spirometry, training and education of employees, regularly administered periodic questionnaires, medical assessment for abnormal questionnaire responses, process for early reporting and investigation of symptomatic employees and incidents, group data review and management reporting. Although regional differences exist regarding availability of specialized services, we have successfully implemented this programme in parts of North America, Europe and Latin America, and are currently implementing elsewhere. These simple control measures are relatively inexpensive and can be applied in even small business settings. It is recommended that all employers who manufacture, handle or use isocyanate-containing products consider such a strategy.     

The managed care revolution: how medical technologists have tolerated the change

A repeated cross-sectional study on the psychological profiles and interpersonal styles of highly stressed medical technologists (perfusionists) has found remarkable consistency in internal psychological profiles and differences in interpersonal dynamics over a 6-year period. Six years ago a longitudinal study was begun to track the psychological profiles of perfusionists. Surgeons can repair cardiac defects only after a beating heart has been stopped. In order for the brain and other organs to survive cardiac surgery, they must be perfused with well-oxygenated blood. As a result, the life of every cardiac surgery patient literally sits in the hands of the cardiac perfusionist. The stress of placing patients on and off the 'pump' is one that is experienced by cardiovascular perfusionists on a daily basis. This stress has been likened to that of air traffic controllers who continually prepare planes for take off and/or landing. In the 6 years between studies, medical technologists have changed very little psychologically. They remain very well balanced. However, there have been significant changes in their interpersonal behaviours. Instead of the 'well-balanced' interpersonal profiles of 6 years ago, there is a higher degree of assertiveness/aggressiveness being reported. Managed Care has begun to impact interpersonal behaviours but has not yet altered the more resilient platform of internal psychological balance.     

Occupational molybdenum exposure and a gouty electrician

BACKGROUND: Molybdenum is an essential trace element and a component of xanthine oxidase, which catalyses the formation of urate. The toxicity of molybdenum in humans is considered to be low, but hyperuricaemia and gout-like symptoms have been observed sporadically. METHODS: A case of hyperuricaemia and gouty arthritis in a young man with occupational exposure to molybdenum is described. Improvement during an exposure-free period was followed by a relapse after a reconstruction designed to quantify his molybdenum exposure. CONCLUSION: This case seems to represent the first observation of gout associated with occupational molybdenum exposure, but the association might also be entirely circumstantial.     

Rationalization as a key stressor for public sector employees: An organizational case study

Public sector organizations throughout Europe have been subjectto cuts in Government spending, allied to demands for enhancedefficiency and effectiveness. Consequently, many have embarkedupon radical programmes of change which potentially have anadverse effect upon the psychological well-being of employees.This study aimed to assess linkages between organization changeand the psychological well-being of employees within the Swedishsocial insurance organization Försäkringskassan. Acase study approach was adopted for the investigation whichwas carried out within the Halland region between February andJune 1995. A questionnaire which included the Cultural Auditand the General Well Being Questionnaire was distributed tothe organization's 456 employees in Halland. Questionnaireswere returned by 246 employees (54.6%), reflecting the employmentstructure of the organization. The findings revealed that manyissues associated with the process of rationalization and changewere of concern to employees. Statistical analyses revealedthat these were linked to their relatively high levels of ‘anxiety’and their symptoms of being ‘worn out’. This studyindicates that the process of organization change is stressfulfor employees within Försäkringskassan. As publicsector organizations throughout Europe are subject to similarpressures and are being forced to embark upon change programmes,it is suggested that they take cognizance of the findings ofthis investigation when making decisions regarding the planningand implementation of organization change.     

Evidence-based care for low back pain in workers eligible for compensation

BACKGROUND: Although guidelines for the management of low back pain have been promoted, few studies have assessed their effectiveness. One previous study did not include patients with workers' compensation claims. AIM: To assess the efficacy of evidence-based care for acute low back pain in patients eligible for workers' compensation. METHODS: In a prospective audit, workers in a health service who presented with acute low back pain were offered the option of usual care from their general practitioner or care provided by a staff specialist who practiced according to evidence-based guidelines. Outcomes were measured in terms of return to normal duties, time off work, recurrence of pain or persistence of pain. RESULTS: Evidence-based care was accepted by 65% of injured workers. Compared with those who elected usual care, these workers had less time off work, spent less time on modified duties and had fewer recurrences. A significantly greater proportion (70%) resumed normal duties immediately, and fewer developed chronic pain, than those managed under usual care. Three types of patients were identified: those who complied readily with evidence-based care, those who initially expressed firm beliefs about how they should be managed and those with occupational psychosocial factors. CONCLUSIONS: Evidence-based care can be successful in retaining patients at work, reducing time off work or on modified duties and reducing recurrences and chronicity. The gains are achieved by conscientiously talking to the patients, and not by any particular or special passive interventions.