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Estudio de la medicación prescrita a las personas afectadas de conductas hostiles sistemáticas en su ámbito laboral

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Universitat de Barcelona. Departament de Farmàcia i Tecnologia Farmacèutica

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[spa] Fundamento y objetivo: El acoso laboral sistemático (ACS), a pesar de las diferentes tratamientos farmacológicos a largo plazo y tratamientos no farmacológicos, conduce a una alta tasa de incapacidades permanentes y graves trastornos mentales. El objetivo de esta comunicación es analizar la prescripción de medicamentos para el tratamiento de enfermedades, trastornos, síntomas y signos que experimentan los afectados de ACSa, teniendo en cuenta el diagnóstico establecido por los MAP o psiquiatras.

Configuración y método: Estudio observacional, longitudinal, basado en la revisión de los registros médicos de las personas afectadas por HSW.

Principales medidas de resultado: datos socio-demográficos, días de incapacidad temporal, el período de HSW psicológica, los principales diagnóstico de acuerdo a la Clasificación Internacional de Enfermedades (CIE-10), la prescripción patrón de acuerdo con la clasificación ATC.

Resultados: 50 pacientes fueron incluidos en el estudio (edad media: 45,5 años; 62% mujeres). Los períodos medios de ACS y de ILT eran 4 años y 413 días respectivamente. Los principales diagnósticos fueron 76,5% F40-48 y el 23,1% F30-39 por médico de cabecera y el 49,4% F30-39 y del 42,1% F40-48 por el psiquiatra. El número total de prescripciones fue 909, incluyendo 67 diferentes principios activos, principalmente del grupo N de la clasificación ATC (88%), dirigidos a mitigar los síntomas mentales y lograr la remisión completa de los síntomas de la enfermedad mental. El restante (12%) se utiliza para tratar el estado psicosomático aparato locomotor, digestivo, cardiovascular, endocrino, dermatológicas infecciosas, respiratorias y los trastornos de dolor crónico.

Los psiquiatras se centran su actividad en la depresión y, así, su prescripción es el 49% de los antidepresivos en comparación con el 29% de los ansiolíticos. Además, la prescripción de antidepresivos aproximadamente coincide con el porcentaje de pacientes con diagnóstico de depresión (43%), mientras que el porcentaje de casos diagnosticados de ansiedad (53%) es muy superior que receta ansiolíticos. Sin embargo, la Guía NICE para los estados depresivos que en el caso de los asociados síntomas de la depresión y la ansiedad, la depresión merece una atención prioritaria.

Conclusiones: Los diagnósticos de los psiquiatras son consistentes con los criterios establecidos en la literatura internacional al describir los trastornos mentales graves y discapacitantes que afectan a HSW psicológico. La prescripción de antidepresivos está de acuerdo con el enfoque de diagnóstico informado por todos los especialistas, y también está de acuerdo con las recomendaciones de NICE Directrices para la depresión.

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[eng] Objectives: The first aim of this study was to examine the possible association of long standing Systematic psychological harassment at work (SPHW) with psychiatric disorders and its characteristics. The second aim was to analyze drug prescription used to treat diseases, disorders, symptoms, and signs of those affected with psychological SPHW, taking into account the established diagnosis by the General Physician (GP) or Psychiatrists.

Method and study subjects: 

Design: Longitudinal observational study with follow up focused on persons undergoing a long duration SPHW; based on the review of medical records of people affected by SPHW

Total length of the follow up period was 6 years, from 2006 to 2012. Mean duration of follow up was 3.1 years (range 1.1-6.3 years). 

Setting: Patients who voluntarily attend to a Catalonia Harassment Victims association (Associació de Víctimes d’Assejament laboral de Catalunya: AVALC) asking for psychological and laboral aid.

Subjects: 132 persons were recruited along a seven years period, 84 women (63.6%) and 48 men (36.4%). Mean age was 45.5 years (SD ± 9.8), 43.8 years for women and 48.3 years for men (p= 0.114).

SPHW was measured by self-reported data. All participants were assessed using several neuropsychological instruments such as the Beck Scale, the Hamilton Depression Scale, the Echeburua Scale, the PDS (Posttraumatic Diagnostic Scale) and the LIPT (Leymann Inventory of Psychological Terrorization).

Medical records were examined to verify all the diagnosis affecting to the participants.

After checking the medical records, only 50 cases (37.3%), 31 women and 19 men, had verified psychiatric diagnostics, according to ICD-10 criteria.

Main outcome measures: 

- Socio-demographic data: age, gender

- Work environment: types of harassers, mainly distributed by work sectors, public administration workers and private organizations workers, days of temporary disability, period of SPHW.

- Main diagnosis according to International Classification of Diseases ICD-10 

- Type of assistance: primary care, mental health unit, emergency department, neurologist or occupational health unit. 

- Previous pharmacotherapeutical history including all prescribed drugs (generic or brand) related with working problems and concomitant medication, number of prescriptions, active principles (DCI), reason for prescription, dose and dosing interval, duration of treatment, and number of drugs per patient.

- Established treatment planning (pharmaceutical care) designed to detect, prevent and solve potential or acute problems related with the prescribed drugs, such as adherence, interactions, collateral effects, negative outcomes, effectiveness and safety.

- Prescription pattern according to Anatomical, Therapeutic, Chemical Classification System (ATC classification).

- Most prescribed active principles and percentages of utilization.

Key terms: 	Systematic psychological harassment at work, mobbing, workplace bullying, stress, occupational health, work environment, psychosocial factors mental health disorders, gender, posttraumatic stress disorder, major depression disorder, depression, anxiety, comorbidity, insomnia, somatic disorder, prevalence, epidemiology, cost mental disorder, treatment / pharmacotherapy/ drug, compliance.

Background/Introduction

The phenomenon of systematic psychological harassment at work (SPHW) first described by Heinz Leymann, refers to systematic and prolonged exposure to frequent hostile behaviours at work. SPHW is commonly considered as an expression of violent behaviour. SPHW has been defined as ‘‘harassing, offending, socially excluding someone or negatively affecting someone’s work tasks...” it has to occur repeatedly and regularly (e.g., weekly) and over a period of time (e.g., about six months). However, there is no accepted common definition as yet and different terminology is used as synonym of bullying (e.g., harassment, mobbing, emotional abuse, victimisation, psychological abuse at work).

Research about this topic has dramatically increased in the last years. These behaviours may lead to the stigmatisation and victimization of the exposed individuals. 

A reciprocal relationship between SPHW and mental distress has been described. Several studies have shown that SPHW is associated with mental distress. Furthermore, mental distress was shown to be a predictor of bullying.

It seems that experiencing workplace bullying can contribute to mental distress, but individual characteristics may also contribute to the perception of bullying. Thus, a significant relationship between general proneness to negative feelings and work victimization has been described. 

A theoretical framework, the cognitive theory of trauma, proposes the post-traumatic stress disorder (PTSD) as the result of systematic psychological harmful events. The traumatic potential of bullying is unquestionable. So, the path from job demands to PTSD through bullying seems plausible.   

PTSD is a severe anxiety disorder that can be developed after exposure to any event that results in psychological trauma. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increased arousal, such as difficulty falling or staying asleep, anger, and hyper vigilance. Diagnostic criteria require that symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.

Exposure to intense bullying at work may change the individual’s perceptions of their work-environment and life in general to one of threat, danger, insecurity and self-questioning, which may result in emotional, psychosomatic and psychiatric problems, even affecting the personal and familiar relationships of the victims. 

Most studies examining the relationship between psychosocial work characteristics and mental health outcomes, ranging from symptoms and psychological distress to diagnosed psychiatric disorders, have been cross-sectional and, therefore, the causal association between work stressors and mental health remains uncertain.

The aim of this study is to describe and analyze the possible relationship between SPHW characteristics and the subsequent psychiatric diagnoses, such as the presence of PTSD symptoms as a possible consequence of workplace bullying-related victimization. PTSD in the workplace may be a common problem and there has been scarce research about this topic (32).

RESULTS

Mean duration of SPHW was 4.0 years (SD ± 2.8), 3.7 years for women and 4.6 years for men (p= 0.226). 14% of participants suffered SPHW along 3 years or less, 48% from 3 to 6 years, 30% from 6 to 9 years and 8% more than 9 years. In 62.7% of cases, the harassers were hierarchic superiors and in 9.4% of cases companions and/or collaborators contributed to bullying.

In 62.7% of cases, the harassers were hierarchic superiors and in 9.4% of cases companions and/or collaborators contributed to bullying.

Cases were mainly distributed by work sectors as follows: 28.4% public administrations, 23.2% commercial sector, 23.2% industrial sector and 14.0% services.

In our sample, we included 35.6% of public administration workers and 64.4% of private organizations workers. Despite of the greater proportion of private organization workers, we found a high number of worked years in the same organization: 25% of cases with 20 or more years worked at the same organization. The distribution was as follows: 8.3% less than 1 year, 25.0% from 1 to 5 years, 26.5% from 5 to 10 years, 6.8% from 10 to 15 years, 8.3% from 15 to 20 years, 12.1% from 20 to 25 years, 4.5% from 25 to 30 years, 6.1% from 30 to 35 years and 2.3% from 35 to 40 years.

The mean number of diagnoses for each patient was 4.2 (range 1-7). Persons with previous mental disorders were excluded. The remaining participants met no criteria or were lost along the follow-up period.

All of them showed a follow-up period longer than 30 months. Mean duration of follow up for this group was 3.8 years (range 2.7-6.3 years). 

The main diagnoses were 76.5% F40-48 and 23.1% F30-39 by GP, and 49.4% F30-39 and 42.1% F40-48 by psychiatrist. The most frequent psychiatric diagnoses were Posttraumatic Stress Disorder (PTSD) was the most often diagnosed disorder (44.0%). Major depression has been developed by 20% of patients with important comorbidity, mainly physical symptoms as insomnia, headache, digestive disorders, etc. 

Significant differences were found in the association of SPHW length with type of subsequent psychiatric diagnosis (p=0.015) and public/private job (p=0.047). Psychiatric diagnoses by gender showed significant differences for PTSD (p=0.043), generalized anxiety (p=0.041) and minor depression episodes (p=0.049).

One case of suicide was registered (0.8%) and 3 cases of autolysis attempts (2.3%).

All participant patients presented sick leaves. Mean length of temporary disability was 13.8 months (SD ±6.7), 13.2 months for women and 14.8 months for men. Sick leaves duration was slightly higher for men, but no significant differences by gender were observed (p= 0.417). 

On the other hand, significant differences were observed in the mean duration of sick leaves by diagnosis. Mean values were 9.5 months for adaptation disorders, 11.6 months for generalized anxiety, 11.7 months for minor depression episodes, 11.9 months for major depression and 17.2 months for PTSD (p=0.019). We also found significant differences in the mean duration of sick leaves by public/private job. Mean values were 11.7 months for private jobs and 17.6 months for public employments (p=0.002).

Significant differences were found in the mean age of the psychiatric diagnoses. Cases with diagnosis of adaptation disorders were the youngest and with diagnosis of major depression were the oldest (p=0.019). 

SPHW length seems related with the type of subsequent psychiatric diagnosis. The mean SPHW length was longer for the more severe disorders, PTSD and depression, and shorter for anxiety and adaptation disorders. So, 1.9 years for adaptation disorders, 2.2 years for generalized anxiety, 3.9 years for minor depression, 4.6 years for major depression and 5.1 years for PTSD (p=0.015). Significant differences were also found in the association between SPHW length and public/private job. Mean values were 3.4 years for private jobs and 5.0 years for public jobs (p=0.047).

There were 909 prescriptions, including 67 different active principles (88%). Most of them were from the N group of the ATC classification, which targeted a mitigation of mental symptoms and achievement of complete remission. The remaining 12% prescriptions were used to treat psychosomatic symptoms including locomotive, digestive, cardiovascular, endocrine, infectious, dermatological, respiratory, and chronic pain disorders. 

In our study, 92% of patients are treated with both anxiolytic and antidepressant drugs. General Physicians focus on anxiety, these accounts for 70% of anxiolytic prescribing, in comparison to them being responsible for 20% of antidepressant prescribing. Nevertheless, the NICE Guidelines for Depression state that if a case is presented in which symptoms of both depression and anxiety coexist, the former deserves priority attention. 

Psychiatrists focus on depression; this accounts for 49% of antidepressant prescribing, in comparison to them being responsible for 26.3% of anxiolytic prescribing. Furthermore, the number of antidepressants prescribed is roughly in accordance with the percentage of patients diagnosed with depression (43%), while the percentage of diagnosed anxiety cases (53%) is higher than the amount of anxiolytics prescribed. 

Treatment pattern has been successful in 34% of SPHW with comorbidity, post-traumatic stress syndrome (PTSD) and major depression episodes (MDE). Gender differences have been observed in the successful rates: 47.4% for men and 25.8% for women. 38% of SPHW with associated major depression disorder (MDD) have achieved a remission. Gender differences have been observed in the successful rates: 47.4% for men and 32.3% for women. 

The total number of patients in not remission is 17 (34%), 10 women (20%) and 7 men (36.8%). These patients are treated with both antipsychotic drug (N05A) and another antidepressant (N06AX) drugs. Antipsychotic drugs are almost exclusively prescribed by psychiatrists in 88%.

DISCUSSION

An important limitation of the study is its lack of generalization, because we have focused on diagnosed cases and not in general population. But, in the other hand, there is scarce research focused on persons with a long history of intense bullying. A second limitation is that the data were self-reported, which raises the issue of common method variance. However, other methods, such as observer ratings of working conditions, may be equally affected by bias.

Participants in the study have undergone very long periods of SPHW, so it can be expected that psychological or psychiatric consequences should be more severe than those reported by other studies. It has been described a significant correlation between the duration and intensity of SHPW and the subsequent psychiatric symptoms. PTSD is a severe consequence of important traumatic events. Heterogeneity in PTSD diagnosis is a complex factor which should be assessed. It is not the purpose of this paper to solve the complex issue of the appropriateness of PTSD diagnosis as a consequence of bullying, which is related to the conceptualization of bullying as an overwhelming traumatic event. However, association between SPHW and PTSD have been reported by a large number of studies, most of them having a cross-sectional design. In our data, PTSD incidence in patients SPHW is higher than the described in the literature. It may be partially due to the longitudinal design of the study. The long length of SPHW jointly with the prolonged follow up period (mean value: 3.1 years) could lead into a higher PTSD development ratio. A key question in this relationship is how long do the psychological effects of bullying persist over time, independently of SPHW duration. This question remains uncertain and reveals the need of longitudinal studies with long enough periods of follow up.

Association between depression and SPHW is well documented. Moreover, a meta-analysis collecting epidemiological data calculated summary estimates for the effects of work stress: the average risk of depression across all studies weighted by the number of participants was 1.2 to 1.4 fold. Our results show a 20% incidence of major depression cases, probably due to the characteristics of SPHW, specially its long length.

Gender has been found to be the strongest predictor of Post-Stress Traumatic Disorder (PSTD). Our results agree with the important role of gender. Although WPB duration seems to be highly correlated with the development of PTSD, our data show longer length of SPHW with lower incidence of PTSD for males and shorter length of SPHW with higher rates of PTSD for females.

A great number of patients were lost along the follow-up period (32.1%) and, so, it could not be verified the correct diagnosis, if any, and its possible relation with SPHW. However, the heavy utilization of psychotropic drugs seems to be a strong indicator of severe mental disorders.

The high number of withdrawals may be probably due to the characteristics of participants. Persons attending a victims association in a desperate situation, after a long suffering time, need strong and urgent aid. Solving the SPHW problem is a complex and difficult question, so patients go on looking for new options.

Comorbidity is the main prognosis factor for transitory disability length. The high number of diagnoses for each patient observed in our study probably influences the long length of sick leaves. Major psychiatric disorders are commonly related to work disability and, usually, they are an important potential factor for unemployment.

It has been argued that the association between work characteristics and health is due to confounding by social class. Thus, poor work environmental characteristics are merely a marker of low socioeconomic position. But even after adjustment for social position, in occupational cohorts of homogeneous social status, work characteristics are still important determinants of psychological distress.

Mental health problems can take years to develop but the cross-sectional studies explore a reduced time period. In our data the minimum follow-up period is 30 months, so the described relationship between WPB and psychiatric disorders should be more consistent.



CONCLUSIONS

Longer length of SPHW is associated with more severe psychiatric diagnoses. As mental health problems can take years to develop, long follow up periods are needed to identify the psychiatric consequences of SPHW. 

The diagnoses made by psychiatrists were consistent, but GP diagnoses weren’t it, with the criteria established in the international literature describing severe and disabling mental disorders affecting psychological of SPHW. The prescribing of antidepressants correlated with the diagnostic approach used by specialists, and was also in accordance with the NICE Guidelines for depression. 

SPHW despite of different long-term pharmacological and non-pharmacological treatments, leads to a high rate of permanent disabilities and severe mental disorders.

Prescription of drugs in Mental Health settings by GP is based on so-called target symptoms (depression, anxiety, insomnia and somatic) representing 93.9% of total prescription. However, Psychiatrists prescription is based on an another target symptoms (psychosis diseases, depression, anxiety, insomnia, suicide risk, aggressive behaviour, attention, phobia, mania, neurosis, agitation, comorbid psychiatric disorders) 

Chronic insomnia in patients with major depression disorder (MDD) is underdiagnosed and undertreated, despite of its high prevalence in this type of patients with SPHW.

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Tesis Doctorals - Departament - Farmàcia i Tecnologia Farmacèutica

# metadata.dc.title[].value
Estudio de la medicación prescrita a las personas afectadas de conductas hostiles sistemáticas en su ámbito laboral