Work stress and changes in heart rate variability among employees after first acute coronary syndrome: a hospital-based longitudinal cohort study.

Background: Work stress is considered as a risk factor for coronary heart disease, but its link with heart rate variability (HRV) among heart attack survivors is unknown yet. The aim of this study was to investigate associations between baseline work stress and the changes of HRV over one-year after onset of acute coronary syndrome (ACS). Methods: Hundred and twenty-two patients with regular paid work before their first ACS episode were recruited into this hospital-based longitudinal cohort study. During hospitalization (baseline), all patients underwent assessments of work stress by job strain (JS) and effort-reward imbalance (ERI) models, and were assigned into low or high groups; simultaneously, sociodemographic and clinical data, as well depression, anxiety, and job burnout, were collected. Patients were followed up 1, 6, and 12 months after discharge, with HRV measurements at baseline and each follow-up point. Generalized estimating equations were used to analyze the effects of baseline work stress on HRV over the following 1 year. Results: After adjusting for baseline characteristics and clinical data, anxiety, depression, and burnout scores, high JS was not associated with any HRV measures during follow-up (all p > 0.10), whereas high ERI was significantly related to slower recovery of 5 frequency domain HRV measures (TP, HF, LF, VLF, and ULF) (all p < 0.001), and marginally associated with one time domain measure (SDNN) (p = 0.069). When mutually adjusting for both work stress models, results of ERI remained nearly unchanged. Conclusion: Work stress in terms of ERI predicted lower HRV during the one-year period after ACS, especially frequency domain measures.

[Sociological Research and Teaching in the Context of Medical Faculties - An Autobiographical Report]. / Soziologische Forschung und Lehre im Kontext medizinischer Fakultäten ­ Ein autobiographischer Rückblick.

With the introduction of medical psychology and medical sociology as examination subjects in the medical curriculum, as enacted by the year 1970 in Germany, medical faculties established professorships and departments for these disciplines. This raised the concern of how the two separate scientific cultures of the social and behavioural sciences and of medicine, rooted in basic sciences, could reconcile their teaching and research activities in a constructive way. It turned out that the quality and the thematic affinity of new research aligning with core medical interests were important preconditions of successful integration of the new disciplines. This paper exemplifies a respective success in case of a scientific development in medical sociology. Based on a theoretical model, a longstanding, internationally collaborating research program analysing social determinants of stress-related disorders resulted in a series of innovative insights. Furthermore, the paper illustrates close links between biographical luck and structural opportunities and constraints, and it emphasizes the important role of committed inter-disciplinary scientific collaboration.

Prospective Association of High Effort and Low Reward Imbalance at Work with Risk of Diabetes: A Cohort Study in US Workers.

BACKGROUND: The contribution of psychosocial stress in the workplace to development of type 2 diabetes mellitus (T2DM) is not well investigated. As most studies were conducted in Europe, a further test from the USA seems well justified. The objective of the current investigation was to examine prospective associations of work stress based on the effort-reward imbalance model with risk of T2DM in a national sample of US workers. METHOD: Using data from the national population-based Mid-life in the United States (MIDUS) study with a prospective cohort design and a 9-year follow-up period, the effects of a ratio combining data on effort and reward at work (ER ratio) at baseline on risk of T2DM at follow-up were examined in 1493 workers who were free from diabetes at the baseline survey, applying multivariable Poisson regression analysis. RESULTS: During the follow-up, 109 individuals (7.30%) reported onset of diabetes. The analyses demonstrated a significant association between continuous data of the E-R ratio and risk of diabetes (RR and 95% CI = 1.22 [1.02, 1.46]), after adjustment for modifiable and non-modifiable risk factors at baseline. A dose-dependent response was observed with trend analysis when using quartiles of the E-R ratio. CONCLUSION: In the US workers, high effort in combination with low reward at work was significantly associated with elevated risk of T2DM 9 years later. The risk profiles of diabetes should be adapted in consideration of psychosocial work environment and taken into account by conceptualizing prevention programs of chronic non-communicable diseases.

Psychosocial Occupational Health-A Priority for Middle-Income Countries?

In response to new developments of work and employment in high-income countries (HICs), psychosocial aspects of work and health have received increased attention. In contrast, middle-income countries (MICs) are mainly concerned with severe challenges of noxious- and dangerous-material work environments, poor employment conditions, and deficient social policies, which leaves the psychosocial aspects with a marginal role, at best, in occupational health. More recently, differences between these two worlds were even aggravated by the COVID-19 pandemic. Yet, with economic globalisation and the growing worldwide interconnectivity, the world of work in MICs is being rapidly transformed, starting to share several concerns with the modern Western societies. In this process, psychosocial occupational health will become an increasingly pressing issue. This contribution explores the extent to which psychosocial aspects of work and health are already addressed in research originating from MICs. Using a narrative review approach, a selective focus on recent findings from two regions, Asia Pacific and Latin America, revealed an increasing interest in work stress-related problems, but a restricted impact of the respective research findings. It is hoped that future scientific developments in MICs will enrich the international state of the art in this field.

Socioeconomic inequalities, psychosocial stressors at work and physician-diagnosed depression: Time-to-event mediation analysis in the presence of time-varying confounders.

OBJECTIVES: There is evidence that both low socioeconomic status (SES) and psychosocial stressors at work (PSW) increase risk of depression, but prospective studies on the contribution of PSW to the socioeconomic gradient of depression are still limited. METHODS: Using a prospective cohort of Quebec white-collar workers (n = 9188 participants, 50% women), we estimated randomized interventional analogues of the natural direct effect of SES indicators at baseline (education level, household income, occupation type and a combined measure) and of their natural indirect effects mediated through PSW (job strain and effort-reward imbalance (ERI) measured at the follow-up in 1999-2001) on incident physician-diagnosed depression. RESULTS: During 3 years of follow-up, we identified 469 new cases (women: 33.1 per 1000 person-years; men: 16.8). Mainly in men, low SES was a risk factor for depression [education: hazard ratio 1.72 (1.08-2.73); family income: 1.67 (1.04-2.67); occupational type: 2.13 (1.08-4.19)]. In the entire population, exposure to psychosocial stressors at work was associated with increased risk of depression [job strain: 1.42 (1.14-1.78); effort-reward imbalance (ERI) 1.73 (1.41-2.12)]. The estimated indirect effects of socioeconomic indicators on depression mediated through job strain ranged from 1.01 (0.99-1.03) to 1.04 (0.98-1.10), 4-15% of total effects, and for low reward from 1.02 (1.00-1.03) to 1.06 (1.01-1.11), 10-15% of total effects. DISCUSSION: Our study suggests that PSW only slightly mediate the socioeconomic gradient of depression, but that socioeconomic inequalities, especially among men, and PSW both increase the incidence of depression.

Managers perception of hospital employees' effort-reward imbalance.

OBJECTIVE: Hospitals are frequently associated with poor working conditions that can lead to work stress and increase the risk for reduced employee well-being. Managers can shape and improve working conditions and thereby, the health of their teams. Thus, as a prerequisite, managers need to be aware of their employees' stress levels. This study had two objectives: At first, it aimed to test the criterion validity of the Effort-Reward Imbalance (ERI) questionnaire measuring psychosocial workload in hospital employees. Secondly, mean scales of the ERI questionnaire filled in by employees were compared with mean scales of an adapted ERI questionnaire, in which managers assessed working conditions of their employees. METHODS: Managers (n = 141) from three hospitals located in Germany assessed working conditions of their employees with an adapted external, other-oriented questionnaire. Employees (n = 197) of the mentioned hospitals completed the short version of the ERI questionnaire to assess their working conditions. Confirmatory factor analyses (CFA) were applied to test factorial validity, using the ERI scales for the two study groups. Criterion validity was assessed with multiple linear regression analysis of associations between ERI scales and well-being among employees. RESULTS: The questionnaires demonstrated acceptable psychometric properties in terms of internal consistency of scales, although some indices of model fit resulting from CFA were of borderline significance. Concerning the first objective, effort, reward, and the ratio of effort-reward imbalance were significantly associated with well-being of employees. With regard to the second objective, first tentative findings showed that managers' ratings of their employees' effort at work was quite accurate, whereas their reward was overestimated. CONCLUSIONS: With its documented criterion validity the ERI questionnaire can be used as a screening tool of workload among hospital employees. Moreover, in the context of work-related health promotion, managers' perceptions of their employees' workload deserve increased attention as first findings point to some discrepancies between their perceptions and those provided by employees.

Social inequalities, stressful work and non-fatal cardiovascular disease: follow-up findings from the CONSTANCES Study.

BACKGROUND: Studies show that a disadvantaged socioeconomic position (SEP) and psychosocial stress at work are both independently associated with an increased risk of cardiovascular disease (CVD). But it is not clear if the effect of stress at work on CVD varies by SEP. METHODS: We used baseline and follow-up data from the French population-based cohort study CONSTANCES, including 48 383 employed women and men aged 30-70 years. Three SEP indicators (education, income, occupation), stressful psychosocial work as measured by effort-reward imbalance, pre-existing CVD and confounders were assessed at baseline, and incident non-fatal CVD events reported during annual follow-up (up to five follow-ups) were used as outcomes. The effect modification hypothesis was both investigated on an additive and multiplicative scale. RESULTS: SEP was inversely associated with CVD risk (eg, for low vs high income, OR 1.28 (95% CI 1.12 to 1.46)), and for all three components of stressful work CVD risks were significantly increased (eg, for effort-reward ratio OR 1.26 (95% CI 1.17 to 1.36)). Employees with a disadvantaged SEP showed moderately increased effect sizes of stressful work on CVD. However, no clear evidence of an effect modification was found. CONCLUSIONS: Disadvantaged SEP and stressful work contribute to higher CVD risk in this cohort. Despite moderately increased effect sizes for disadvantaged SEP groups, no evidence was found to support an effect modification hypothesis.

Promoting good and sustainable work in occupational health education.

BACKGROUND: The world of work is facing severe challenges due to rapid technological change, globalization, climate change and, more recently, the Covid-19 pandemic. Occupational health professionals must deal with these challenges, but it is unclear how well they have been prepared for this task by their academic training programmes. AIMS: To explore content and learning objectives related to these challenges in the curricula of Occupational Medicine (OM) and Occupational Safety, Industrial Hygiene and Ergonomics (OSH), we conducted an online survey among academic leaders of these programmes in universities of several European countries. In addition, related programmes in Human Resource Management (HRM) training were included. METHODS: Selected study programmes were explored in terms of the main topics and learning objectives related to the challenges for promoting good and sustainable work in universities in Europe. The study programmes were identified through contacts with professional associations and a website search. Given the exploratory, non-representative study design, data analysis was limited to description. RESULTS: OM and OSH programmes addressed the above challenges to a very limited extent, except for their disciplinary approach to work-related diseases and injuries. In contrast, HRM programmes were dealing more extensively with globalization, climate change and digitisation. CONCLUSIONS: Significant limitations of knowledge and competences in dealing with the key challenges of the modern world of work were identified. More relational, ethical and interdisciplinary learning is needed in these programmes, addressing core issues of today's world of work.

Unrewarding work and major depressive episode: Cross-sectional and prospective evidence from the U.S. MIDUS study.

Depression is a serious mental health condition and is the leading cause of disability worldwide. Previous research has demonstrated that work stress may contribute to the development of depression through psychophysiological pathways. The present study assessed associations of work stress - in terms of the effort-reward imbalance (ERI) model measuring unrewarding work - with major depressive episode (MDE). Data were from the Mid-life in the United States study, a national, population-based sample of U.S. workers with 9-year follow-up prospective cohort design. The cross-sectional sample at baseline had 2204 workers, and the prospective sample had 1591 workers at follow-up (78.7% follow-up rate). Multivariable Bayesian logistic regression and Poisson regression were applied for examining cross-sectional and prospective associations, respectively. ERI was assessed by a validated 17-item scale at baseline, and MDE in the past 12 months was assessed by the Composite International Diagnostic Interview Short Form at both baseline and follow-up. It was found that ERI at baseline was associated with higher odds of prevalent MDE in the cross-sectional sample (OR = 1.47, HPD interval [1.26-1.69]), and with higher risk of MDE at follow-up in the prospective sample (RR = 1.29, HPD interval [1.01-1.60]). In both cross-sectional and prospective analyses, strongest associations were observed among workers with the highest quartile of ERI, after adjusting for demographic, socioeconomic, lifestyle, and other psychosocial factors. The stable and robust findings strengthen and extend previous findings that unrewarding work is a risk factor of mental health. If confirmed by further evidence, intervention targeting work stress reduction is warranted.

Association between life events and later depression in the population-based Heinz Nixdorf Recall study-The role of sex and optimism.

BACKGROUND: The association between life event stress and depressive symptoms has not been analyzed in the general population before. METHODS: In the population-based Heinz Nixdorf Recall study, we assessed the association of 1.) the presence of important life events and 2.) life event stress, with the amount of depressive symptoms in univariable linear regressions and in multivariable regressions adjusted for age and sex (model 1) and age, sex and optimism as important determinants of coping with life events (model 2). Presence of life events and life event stress were assessed with the Social Readjustment Rating Scale (SRRS), optimism with the Life Orientation Test-Revised (LOT-R), and depressive symptoms with the 15-item Center for Epidemiological Studies Depression Scale (CES-D). RESULTS: Of the total cohort of 4,814 participants, 1,120 had experienced important life events during the previous 6 months. Presence of important life events was significantly associated with higher CES-D scores (B = 2.6, 95%CI = 2.2 to 3.0, p < .001; model 2) compared to absence of life events. Associations were stronger for women than for men and for pessimists than for optimists. Among the participants with important life events, median (Q1; Q3) stress-score was 45.0 (39.0; 63.0). Stress-scores >Q3 were significantly associated with higher CES-D scores (2.2, 1.1 to 3.3, < .001) with a stronger association in pessimists than in optimists. CONCLUSIONS: Experiencing life-changing events is associated with depression. Women and individuals with pessimistic personality are especially vulnerable which should be considered in prevention strategies.

Stressful work in primary health care and mental health: The role of gender inequities in Brazil.

BACKGROUND: This study aims to analyze the association between occupational stressors, evaluated by the Effort-Reward Imbalance Model (ERI), and the occurrence of common mental disorders (CMD) among healthcare workers (HCW), additionally considering mediation by over-commitment from work (OW) and mediation of gender effects by work stressors. METHODS: Cross-sectional study, including a random sample of 3343 HCWs, from six municipalities of Bahia, Brazil. The ERI scale measured the occupational stressors (main exposure), and the Self-Reporting Questionnaire (SRQ-20) was used to screen for CMD. Data analysis used Structural Equation Modeling techniques to understand the relationships between gender, occupational stressors, and the occurrence of CMD. RESULTS: ERI and OW were associated with CMD. OW mediated the negative effect of ERI on the mental health of HCW. Female workers had higher levels of ERI, OW, and CMD prevalence; the total gender effect on CMD prevalence was mediated by ERI and OW. CONCLUSIONS: The findings highlight the association of work psychosocial stressors and CMD among HCW, including partial mediation by OW. Gender inequalities persisted among HCW, with women most exposed to occupational stressors and CMD. ERI and OW partially mediated the effect of gender on CMD.

Long-term trends in psychosocial working conditions in Europe-the role of labor market policies.

BACKGROUND: Employees have witnessed rising trend in work stress over the last few decades. However, we know a little about country differences in those trends. Our article fills this gap in the literature by examining heterogeneities in trends in working conditions by country groups defined by their amount of investment into labor market policy (LMP) programs. Additionally, we provide findings on differences in occupational inequalities between country groups. METHODS: We use comparative longitudinal data of the European Working Conditions Surveys including cross-sectional information on employees from 15 countries surveyed in Waves 1995, 2000, 2005, 2010 and 2015. Estimation results are provided by three-way multilevel models with employees nested within country-years nested within countries. Our work stress measure is the proxy version of job strain based on the demand-control model. RESULTS: Our regression results indicate that for employees in countries with the least LMP spending job strain increased by 10% from 1995 to 2015 compared to a smaller and insignificant change in middle- and high-LMP countries. In low-LMP countries, inequalities in job strain also widened during the studied period: the gap in job strain between the highest- and lowest-skilled increased by 60% from 1995 to 2015. This contrasts a stable gap in middle- and high-LMP countries. CONCLUSIONS: Our results direct the attention to the vulnerable position of the least skilled and highlight that LMP investments may buffer some of the adverse impacts of globalization and technological changes and effectively improve the labor market situation of the least skilled.

Gender moderates the association between chronic academic stress with top-down and bottom-up attention.

Research on the relationship between chronic stress and cognition is limited by a lack of concurrent measurement of state-anxiety, physiological arousal, and gender. For the first time, we assessed the impact of these factors on top-down/conscious (simple and choice reaction time) and bottom-up/reflexive (saccadic reaction time) measures of attention using CONVIRT virtual-reality cognitive tests. Participants (N = 163) completed measures of academic stress (effort-reward imbalance; ERI) and state-anxiety while heart-rate variability was recorded continuously throughout the experiment. Gender moderated the association between academic stress with the top-down measures (b = -0.002, t = -2.023, p = .045; b = -0.063, t = -3.080, p = .002) and higher academic stress was associated with poorer/slower reaction times only for male participants. For bottom-up attention, heart rate variability moderated the relationship between academic stress and saccadic reaction time (b = 0.092, t = 1.991, p = .048), and only female participants who were more stressed (i.e., ERI ≥ 1) and displayed stronger sympathetic dominance had slower reaction times. Our findings align with emerging evidence that chronic stress is related to hyperarousal in women and cognitive decrements in men. Our findings suggest that higher ERI and sympathetic dominance during cognitive testing was associated with poorer bottom-up attention in women, whereas for men, academic stress was related with poorer top-down attention irrespective of sympathovagal balance.

Adverse employment histories and allostatic load: associations over the working life.

BACKGROUND: Most studies on the health impact of occupational stress use single-point measures of stress at work. This study analyses the associations of properties of entire employment trajectories over an extended time period with a composite score of allostatic load (AL). METHODS: Data come from the French CONSTANCES cohort, with information on adverse employment histories between ages 25 and 45 and a composite score of AL (based on 10 biomarkers, range 0-10) among people aged 45 or older (47 680 women and 45 035 men). Data were collected by questionnaires (including retrospective employment histories) or by health examinations (including blood-based biomarkers). We distinguish six career characteristics: number of temporary jobs, number of job changes, number of unemployment periods, years out of work, mode occupational position and lack of job promotion. RESULTS: For both men and women, results of negative binomial regressions indicate that adverse employment histories are related to higher levels of AL, particularly histories that are characterised by a continued disadvantaged occupational position, repeated periods of unemployment or years out of work. Findings are adjusted for partnership, age and education, and respondents with a health-related career interruption or early retirement are excluded. CONCLUSIONS: Our study highlights physiological responses as a mechanism through which chronic stress during working life is linked to poor health and calls for intervention efforts among more disadvantaged groups at early stages of labour market participation.

Effort-Reward Imbalance at Work and Drug Misuse: Evidence from a National Survey in the U.S.

With the rise of drug misuse among workers in recent years, preliminary research on potential risk factors in the workplace of single-type of drug misuse has been reported. This is the first study to examine cross-sectional associations of work stress, in terms of effort-reward imbalance, with multiple drug misuse (including any drug misuse, opioid misuse, sedatives misuse, cannabis misuse, and other drug misuse) during the past 12 months in a national sample of U.S. workers. Data of 2211 workers were derived from the nationally representative and population-based Midlife in the United States (MIDUS) study. Internal consistency reliability and factorial validity of a 17-item effort-reward imbalance measure were robust and satisfactory. After adjustment for relevant covariates, logistic regression analyses showed that workers experiencing effort-reward imbalance at work had significantly higher odds of any drug misuse (OR and 95% CI = 1.18 (1.03, 1.37)), especially opioid misuse (OR and 95% CI = 1.35 (1.07, 1.69)) and other drug misuse (OR and 95% CI = 1.36 (1.01, 1.83)). The findings suggest that a stressful work environment may act as a determinant of drug misuse, and further prospective evidence is needed.

Adverse employment histories, work stress and self-reported depression in the French CONSTANCES study.

BACKGROUND: Job instability and disadvantaged work were shown to be associated with poor mental health, but few studies analyzed these conditions in a life course perspective. In this study, adverse employment histories are retrospectively assessed and linked to self-reported depression. Furthermore, indirect effects of later stressful psychosocial work in terms of effort-reward imbalance are investigated. METHODS: With data from the French CONSTANCES cohort study of 13 716 male and 12 767 female employees aged 45 and older, we identify adverse employment histories between age 25 and 45, focussing on job discontinuity, job instability and cumulative disadvantage. Direct effects of these conditions on self-reported depression over a period of up to 5 years are analyzed, using discrete-time logistic regression. Indirect effects of stressful work at baseline are examined. RESULTS: Moderately elevated odds ratios of self-reported depression are observed among participants with discontinued employment histories (number of unemployment periods; years out of work for men). Effort-reward imbalance at work is consistently related to elevated risk of self-reported depression and explains parts of the association between discontinuous employment and depression. CONCLUSIONS: Applying a life course perspective to occupational health research extends current knowledge. Specifically, adverse employment histories in terms of recurrent job discontinuity are related to the risk of self-reported depression. This association is partly explained by exposure to a stressful psychosocial work environment. These results can instruct labour market policies and the development of targeted worksite interventions that address disadvantage throughout entire employment trajectories.

[Psychosocial stress at work and disease risks : Scientific evidence and implications for practice]. / Psychosoziale Arbeitsbelastungen und Erkrankungsrisiken : Wissenschaftliche Evidenz und praktische Konsequenzen.

The modern working world makes a significant contribution to the development of diseases, which goes far beyond the field of traditional occupational diseases. Despite technological progress and successful medical healthcare, distinct widely disseminated psychosocial working conditions contribute to a remarkable burden of work-related diseases. By inducing chronic activation of psychobiological stress reactions, they promote the development of various physical and mental disorders. To identify "toxic" constellations within the complexity and variability of modern work environments, a theoretical model is required. It aims at delineating core critical elements at a level of generalization that enables their identification in a wide range of occupations. This article describes the leading theoretical work stress models in the international research and it demonstrates their contribution towards explaining elevated disease risks among employees. Research based on prospective epidemiologic cohort studies focused specifically on depressive disorders and coronary heart diseases. Two theoretical concepts received particular attention, the demand-control and the effort-reward imbalance models. Results derived from meta-analyses indicate increased relative risks of these disorders in the range of 35-80% among those exposed to these stressors compared to nonexposed groups. Finally, practical implications of this scientific evidence for worksite screening and health promoting activities are discussed.

The effect of exposure to long working hours on depression: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates), supported by a large number of individual experts. Evidence from previous reviews suggests that exposure to long working hours may cause depression. In this article, we present a systematic review and meta-analysis of parameters for estimating (if feasible) the number of deaths and disability-adjusted life years from depression that are attributable to exposure to long working hours, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the effect of exposure to long working hours (three categories: 41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on depression (three outcomes: prevalence, incidence and mortality). DATA SOURCES: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies, including the WHO International Clinical Trial Registers Platform, Medline, PubMed, EMBASE, Web of Science, CISDOC and PsycInfo. We also searched grey literature databases, Internet search engines and organizational websites; hand-searched reference lists of previous systematic reviews; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (aged <15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of exposure to long working hours (41-48, 49-54 and ≥55 h/week), compared with exposure to standard working hours (35-40 h/week), on depression (prevalence, incidence and/or mortality). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors independently screened titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined odds ratios using random-effects meta-analysis. Two or more review authors assessed the risk of bias, quality of evidence and strength of evidence, using Navigation Guide and GRADE tools and approaches adapted to this project. RESULTS: Twenty-two studies (all cohort studies) met the inclusion criteria, comprising a total of 109,906 participants (51,324 females) in 32 countries (as one study included multiple countries) in three WHO regions (Americas, Europe and Western Pacific). The exposure was measured using self-reports in all studies, and the outcome was assessed with a clinical diagnostic interview (four studies), interview questions about diagnosis and treatment of depression (three studies) or a validated self-administered rating scale (15 studies). The outcome was defined as incident depression in all 22 studies, with first time incident depression in 21 studies and recurrence of depression in one study. We did not identify any study on prevalence of depression or on mortality from depression. For the body of evidence for the outcome incident depression, we had serious concerns for risk of bias due to selection because of incomplete outcome data (most studies assessed depression only twice, at baseline and at a later follow-up measurement, and likely have missed cases of depression that occurred after baseline but were in remission at the time of the follow-up measurement) and due to missing information on life-time prevalence of depression before baseline measurement. Compared with working 35-40 h/week, we are uncertain about the effect on acquiring (or incidence of) depression of working 41-48 h/week (pooled odds ratio (OR) 1.05, 95% confidence interval (CI) 0.86 to 1.29, 8 studies, 49,392 participants, I2 46%, low quality of evidence); 49-54 h/week (OR 1.06, 95% CI 0.93 to 1.21, 8 studies, 49,392 participants, I2 40%, low quality of evidence); and ≥ 55 h/week (OR 1.08, 95% CI 0.94 to 1.24, 17 studies, 91,142 participants, I2 46%, low quality of evidence). Subgroup analyses found no evidence for statistically significant (P < 0.05) differences by WHO region, sex, age group and socioeconomic status. Sensitivity analyses found no statistically significant differences by outcome measurement (clinical diagnostic interview [gold standard] versus other measures) and risk of bias ("high"/"probably high" ratings in any domain versus "low"/"probably low" in all domains). CONCLUSIONS: We judged the existing bodies of evidence from human data as "inadequate evidence for harmfulness" for all three exposure categories, 41-48, 48-54 and ≥55 h/week, for depression prevalence, incidence and mortality; the available evidence is insufficient to assess effects of the exposure. Producing estimates of the burden of depression attributable to exposure to long working appears not evidence-based at this point. Instead, studies examining the association between long working hours and risk of depression are needed that address the limitations of the current evidence.