[Mental health problems among employees: service use and costs to the German healthcare system]. / Psychische Belastungen bei Erwerbstätigen: Leistungsinanspruchnahme und Kosten für das deutsche Gesundheitssystem.

BACKGROUND: Service use among employees with mental health problems and the associated costs for the health and social system have not yet been systematically analysed in studies or have only been recorded indirectly. The aim of this article is to report the service use in this target group, to estimate the costs for the health and social system and to identify possible influencing factors on the cost variance. METHODS: As part of a multicentre study, use and costs of health and social services were examined for a sample of 550 employees with mental health problems. Service use was recorded using the German version of the Client Sociodemographic Service Receipt Inventory (CSSRI). Costs were calculated for six months. A generalized linear regression model was used to examine influencing cost factors. RESULTS: At the start of the study, the average total costs for the past six months in the sample were €â€¯5227.12 per person (standard deviation €â€¯7704.21). The regression model indicates significant associations between increasing costs with increasing age and for people with depression, behavioural syndromes with physiological symptoms, and other diagnoses. DISCUSSION: The calculated costs were similar in comparison to clinical samples. It should be further examined in longitudinal studies whether this result changes through specific interventions.

Comparison of the Perceived Stress Reactivity Scale with physiological and self-reported stress responses during ecological momentary assessment and during participation in a virtual reality version of the Trier Social Stress Test.

Valid approaches to conveniently measure stress reactivity are needed due to the growing evidence of its health-impairing effects. This study examined whether the Perceived Stress Reactivity Scale (PSRS) predicts cardiovascular and psychological responses to psychosocial stressors during daily life and during a virtual reality (VR) Trier Social Stress Test (TSST). Medical students answered a standardized baseline questionnaire to assess perceived stress reactivity by the PSRS. The PSRS asks participants to rate the intensity of their typical affective responses to common stressors during daily life. They were further asked to participate in a VR-TSST and in an ecological momentary assessment (EMA) over a period of three consecutive workdays during daily life. Blood pressure and self-reported stress were repeatedly, heart rate variability (HRV) continuously measured during the VR-TSST and EMA. Furthermore, participants repeatedly assessed task demands, task control and social conflict during the EMA. Data was analysed using multilevel analysis and multiple linear regression. Results indicate that the PSRS moderates associations between blood pressure (but not HRV) and demands and control during daily life. Furthermore, the PSRS directly predicted self-reported stress, but did not moderate associations between self-reported stress and demands, control and social conflict. The PSRS did not predict physiological and self-reported stress responses to the VR-TSST. This study partly confirmed convergent validity of the PSRS to stress reactivity in daily life. Furthermore, the lack of association between the PSRS and stress responses to the VR-TSST calls for future studies to search for reliable and valid ways to assess stress reactivity.

Investigating information needs and preferences regarding digital mental health services among medical and psychology students in Germany: A qualitative study.

Background: Since 2020, physicians and psychotherapists in Germany can prescribe digital mental health services (dMHSs). However, even future healthcare professionals (HCPs), such as medical and psychology students, remain reluctant to use dMHSs, although they are a risk group for mental health issues themselves. Reasons include scepticism and lacking awareness of dMHSs, which can be addressed by acceptance-facilitating interventions (AFIs) such as information strategies. To date, though, little is known about their information needs. Methods: Semi-structured interviews with n = 21 students were conducted between August and September 2021. Students of legal age studying psychology or medicine at a German university could participate. Interview recordings were transcribed verbatim and content-analyzed according to Mayring, using deductive and inductive coding. Results: Most students reported having little experience with dMHSs. Digital health has barely been raised in their study, even though it was perceived as crucial for personal needs as well as in preparation for their work as HCPs. Students favoured receiving information on and recommendations for dMHSs from their university via, e.g. social media or seminars. Among others, information about data safety, scientific evidence base and application scope were preferred. Additionally, information on costs as well as user reviews seemed to be essential components of information strategies because students were concerned that high costs or low usability would hinder uptake. Conclusions: The results give first insights on how future HCPs would like to be informed on dMHSs. Future research should focus on systematic variations of AFIs' components mimicking real-world decision scenarios to increase the adoption of dMHSs.

[Psychotherapy prescribed by accident insurance consultants : Important component in treatment procedures of the statutory accident insurance]. / D-ärztlich veranlasste Psychotherapie : Wichtiger Baustein im Heilverfahren der gesetzlichen Unfallversicherung.

BACKGROUND: In Germany around 1 Million working and commuting accidents per year are officially registered. Since several years this number is constantly at this high level, only just since the appearance of the actual Covid pandemia significantly lower because of lockdowns and increase of homeoffice workplaces. OBJECTIVE: To ensure the professional care of psychotraumatic sequelae of work-related injuries, in 2012 new regulations were introduced by the DGUV, the national umbrella organization of the German statutory health insurances. This healthcare reform (named "Psychotherapeutenverfahren", verbally translated: psychotherapists' procedure) is looked at 10 years later. Is the new regulation accepted by the surgeons' community? What case constellations can be observed? MATERIAL AND METHODS: The use of this new instrument among trauma surgeons was evaluated by national data for the complete years 2013-2021. Additionally, we include regional data and case reports from a multidisciplinary medical facility including trauma surgery and psychiatry, located in Güstrow (Northeast Germany). RESULTS: Nationwide the percentage of psychotherapy amongst the regular treatment has doubled between 2013 and 2021 from 0.47 to 0.96%. DISCUSSION: Looking at the first 10 years of its clinical implementation, the new German psychotherapy regulation is apparently well accepted by the accident insurance consultants. As data from population based studies are not available, the actual percentage of psychological sequelae of accidents in this cases is not known yet. So there is further need of research and training in this interdisciplinary field to ensure appropriate treatment of victims of work-related accidents. The integration of psychotraumatological facts in the educational agendas of accident insurance consultants has already started.

Physiological reactions to acute stressors and subjective stress during daily life: A systematic review on ecological momentary assessment (EMA) studies.

OBJECTIVE: This review aims to provide an overview of ecological momentary assessment (EMA) studies analyzing stress reactivity during daily life in terms of direct and moderated influence of acute stress on physiological responses. MATERIALS AND METHODS: A systematic literature search was performed on November 29, 2021 using Web of Science, MEDLINE and PsycINFO to identify prospective EMA studies targeting acute stressors or stress under naturalistic conditions, without restrictions of publication date or population. Study quality was assessed for multiple EMA-specific sources of bias. RESULTS: Out of 4285 non-duplicate records, 107 publications involving 104 unique studies were included. The majority of studies assessed acute physiological stress responses primarily through salivary cortisol (n = 59) and cardiovascular outcomes (n = 32). Most studies performed at least three measurements per day (n = 59), and had a moderate risk of recall bias (n = 68) and confounding (n = 85). Fifty-four studies reported a compliance of ≥80%. Direct, non-moderated positive associations were observed between acute stress exposure and concurrent cortisol levels (44%, n = 11/25), systolic (44%, 8/18) and diastolic blood pressure (53%, 8/15) and heart rate (53%, 9/17). Several inter- and intra-individual moderators were identified, such as age, gender, health status, chronic stress, work-related resources, physical activity and stress coping indicators. CONCLUSIONS: About half of the reviewed EMA studies demonstrated direct associations between everyday acute stress exposure and physiological responses, including increased cortisol levels, blood pressure and heart rate. Results further suggested various moderator variables that could help develop tailored prevention strategies and identify groups at higher risk for dysfunctional stress responses. REGISTRATION: PROSPERO-Reg.-No.: PROSPERO 2020 CRD42020163178.

Striving for Health Equity: The Importance of Social Determinants of Health and Ethical Considerations in Pandemic Preparedness Planning.

Since the WHO's "Influenza Pandemic Preparedness Plan" in 1999, pandemic preparedness plans at the international and national level have been constantly adapted with the common goal to respond early to outbreaks, identify risks, and outline promising interventions for pandemic containment. Two years into the COVID-19 pandemic, public health experts have started to reflect on the extent to which previous preparations have been helpful as well as on the gaps in pandemic preparedness planning. In the present commentary, we advocate for the inclusion of social and ethical factors in future pandemic planning-factors that have been insufficiently considered so far, although social determinants of infection risk and infectious disease severity contribute to aggravated social inequalities in health.

Early intervention, treatment and rehabilitation of employees with common mental disorders by using psychotherapeutic consultation at work: study protocol of a randomised controlled multicentre trial (friaa project).

BACKGROUND: Common mental disorders are one of the leading causes for sickness absence and early retirement due to reduced health. Furthermore, a treatment gap for common mental disorders has been described worldwide. Within this study, psychotherapeutic consultation at work defined as a tailored, module-based and work-related psychotherapeutic intervention will be applied to improve mental health care. METHODS: This study comprises a randomised controlled multicentre trial with 1:1 allocation to an intervention and control group. In total, 520 employees with common mental disorders shall be recruited from companies being located around five study centres in Germany. Besides care as usual, the intervention group will receive up to 17 sessions of psychotherapy. The first session will include basics diagnostics and medical indication of treatment and the second session will include work-related diagnostics. Then, participants of the intervention group may receive work-related psychotherapeutic consultation for up to ten sessions. Further psychotherapeutic consultation during return to work for up to five sessions will be offered where appropriate. The control group will receive care as usual and the first intervention session of basic diagnostics and medical indication of treatment. After enrolment to the study, participants will be followed up after nine (first follow-up) and fifteen (second follow-up) months. Self-reported days of sickness absence within the last 6 months at the second follow-up will be used as the primary outcome and self-efficacy at the second follow-up as the secondary outcome. Furthermore, a cost-benefit assessment related to costs of common mental disorders for social insurances and companies will be performed. DISCUSSION: Psychotherapeutic consultation at work represents a low threshold care model aiming to overcome treatment gaps for employees with common mental disorders. If successfully implemented and evaluated, it might serve as a role model to the care of employees with common mental disorders and might be adopted in standard care in cooperation with sickness and pension insurances in Germany. TRIAL REGISTRATION: The friaa project was registered at the German Clinical Trial Register (DRKS) at 01.03.2021 (DRKS00023049): https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023049 .

The Prevalence and Determinants of Being Offered and Accepting Operational Management Services-A Cohort Study.

In Germany, employers are obliged to offer "operational integration management" (OIM) services to employees returning from long-term sick leave. OIM aims to improve employees' workability and to prevent future sick leave or early retirement. This study examined (i) to what extent OIM services are offered to eligible employees, (ii) to what extent offers are accepted and (iii) the determinants of both outcomes. We used data from a cohort of employees eligible for OIM. Thirty-four potential determinants were assessed in 2013 (i.e., the baseline) using participant reports. In 2015 (i.e., the follow-up), participants were asked (a) whether they had ever been offered OIM services by their employer, and (b) whether they had accepted that offer (i.e., the outcomes). We estimated relative risks by multivariable binomial regression to identify predictors based on backward elimination. In total, 36.0% of the participants were offered OIM services and 77.2% of them accepted that offer. The likelihood of an OIM offer at follow-up was elevated in participants with mental impairment, cancer or long-term absenteeism and increased with organizational justice, neuroticism, and company size. The likelihood of accepting that OIM offer was positively associated with mental impairment and decreased with increasing company size.

Description and application of a method to quantify criterion-related cut-off values for questionnaire-based psychosocial risk assessment.

PURPOSE: The psychosocial risk assessment is a systematic intervention process for organizations that aims at improving psychosocial working conditions as well as employee health. Based on a screening of working conditions, interventions to reduce risk factors are implemented and evaluated. What is missing for most screening instruments however are cut-off values to categorize working conditions into uncritical vs. critical, whereas the latter indicates an elevated risk for illness. To estimate and evaluate cut-off values, two studies were conducted using the receiver operating characteristic (ROC) analysis. METHODS: In Study 1, a sample of 229 participants answered an online survey on depression (PHQ) and psychosocial working conditions using a questionnaire (DYNAMIK) that covers five factors important to workers' health: workload, boundary permeability, participation, leader support, and usability. Using the ROC analysis, criterion-related cut-off values were generated to predict depressive symptoms. In Study 2, these cut-off values were used to classify working conditions in the two categories of 'critical' and 'uncritical' in an independent sample (N = 295). It was tested for differences in the results of the two groups concerning the direct criterion of depressive symptoms and the indirect criterion of effort-reward imbalance. RESULTS: In Study 1, cut-off values differed between the five scales and showed different values for sensitivity and specificity. In Study 2, participants exposed to critical working conditions reported more depressive symptoms as well as an effort-reward imbalance. CONCLUSIONS: Cut-off values are useful to identify working conditions as either critical or uncritical. This knowledge is important when deciding which working conditions should be optimized within the context of psychosocial risk assessment.

The Synergistic Effects of Organizational Justice and Trust to Supervisor on Vagal Tone: Preliminary Findings of an Empirical Investigation.

The influence of perceived unfairness at the workplace (organizational injustice) on employee health is well established. Several theories explain the unpleasant and stressful nature of the experience of injustice, using trust as a central element. This study examines the effect of trust to supervisor on the association of perceived injustice with vagal tone-an objective marker for stress experience. Questionnaires assessed organizational justice and trust. Vagal tone was measured by indictors of heart rate variability (HRV), which captured parasympathetic (pNN50, RMSSD, and HF) and parasympathetic and sympathetic (SDNN, and LF) regulation. Synergistic effects were tested by linear regressions with interaction terms between organizational justice and trust to supervisor in 38 managers. Organizational justice was related to HRV indicators that reflect in particular the parasympathetic branch (ßpNN50 = 0.32, p < 0.05; ßRMSSD = 0.27, p < 0.1), and interaction effects with trust to supervisor were also most pronounced there (interaction ßpNN50 = -0.41, p < 0.01; ßRMSSD = -0.47, p < 0.01). In conclusion, the combination of low perceived justice and trust to supervisor appears substantial to the physiological stress threat of employees. Promoting fairness at the workplace might reduce stress; if not possible, trust to supervisor should be enhanced.

The Relationship between Personality Traits with Depressive Symptoms and Suicidal Ideation among Medical Students: A Cross-Sectional Study at One Medical School in Germany.

Medical students are at increased risk of experiencing mental health problems. Certain personality traits may be associated with elevated vulnerability to study-related stress and poor mental health. This study aimed to investigate the relationship between such personality traits and mental health outcomes among medical students. We drew on cross-sectional data from 251 medical students who had been enrolled for one-year at a medical school in Germany. Depressive symptoms were measured using the Patient Health Questionnaire-8 (PHQ-8) and suicidal ideation was assessed by item 9 from the Patient Health Questionnaire-9 (PHQ-9). Personality traits were captured using the Business-Focused Inventory of Personality 6 Factors (BIP-6F). Multivariable logistic regression analyses were used to quantify the associations between work-related personality factors and mental health outcomes, controlling for demographic and social factors. Odds ratios (ORs) as outcome measures with 95% confidence intervals (CIs) were used. After controlling for important confounders, medical students who scored highly on Stability had lower odds of depressive symptoms (OR: 0.19, 95% CI: 0.09⁻0.42, p < 0.001) and suicidality (OR: 0.38, 95% CI: 0.16⁻0.87, p < 0.05) than those with high scores in other work-related personality factors. Findings also showed that those who scored highly on Dominance had greater odds of depressive symptoms (OR: 2.46, 95% CI: 1.22⁻4.97), p < 0.01). Work-related personality-informed interventions, which promote students' mental well-being and reduce academic stress should be considered at various stages of their medical training.

Do Effort and Reward at Work Predict Changes in Cognitive Function? First Longitudinal Results from the Representative German Socio-Economic Panel.

It has been suggested that work characteristics, such as mental demands, job control, and occupational complexity, are prospectively related to cognitive function. However, current evidence on links between psychosocial working conditions and cognitive change over time is inconsistent. In this study, we applied the effort-reward imbalance model that allows to build on previous research on mental demands and to introduce reward-based learning as a principle with beneficial effect on cognitive function. We aimed to investigate whether high effort, high reward, and low over-commitment in 2006 were associated with positive changes in cognitive function in terms of perceptual speed and word fluency (2006-2012), and whether the co-manifestation of high effort and high reward would yield the strongest association. To this end, we used data on 1031 employees who participated in a large and representative study. Multivariate linear regression analyses supported our main hypotheses (separate and combined effects of effort and reward), particularly on changes in perceptual speed, whereas the effects of over-commitment did not reach the level of statistical significance. Our findings extend available knowledge by examining the course of cognitive function over time. If corroborated by further evidence, organization-based measures in the workplace can enrich efforts towards preventing cognitive decline in ageing workforces.

Determinants of patients' needs in asthma treatment: a cross-sectional study.

Patients' needs in asthma remain insufficiently understood and met. We therefore aimed to investigate the potential determinants of patients' needs in asthma treatment. Our study was based on survey data on 189 adults with asthma. Needs were measured using the 13-item Needs in Asthma Treatment questionnaire, which yields a total score and subscale-specific scores ('exacerbations', 'patient expertise', 'handling drugs' and 'drug effects'). We considered age, sex, education, years since diagnosis and anxiety/depression (measured by the Patient Health Questionnaire-4) as potential determinants. Associations were estimated by multivariable linear regression. Overall, we observed that younger age, poor mental health and a more recently established asthma diagnosis were independently associated with increased needs. Information on drug effects was an exception to this pattern as the need in that domain was solely determined by sex (being greater in men). In conclusion, our study provides novel evidence on patient characteristics that are associated with needs in asthma treatment. If confirmed by future studies, our observations may assist healthcare professionals to identify asthma patients with potentially elevated information, support and training needs and could contribute to the development of tailored interventions.

Patients' needs in asthma treatment: development and initial validation of the NEAT questionnaire.

OBJECTIVE: We aimed to develop and tentatively validate an instrument assessing patients' needs related to asthma treatment. METHODS: Patients were recruited through various approaches (e.g. physicians, pharmacies and patient organizations). Utilizing a mixed methods design, we first conducted five focus groups to explore needs among patients. Next, we devised an item pool which was revised, reduced and evaluated by patients. Finally, data from a survey (n = 362) were used to further reduce the item pool and to examine the questionnaire's psychometric properties and validity. RESULTS: Four broad needs categories emerged from the focus groups: (1) information needs; (2) consideration of patient views in diagnosis; (3) consideration of patient views in treatment planning; and (4) addressing patients' fears. We devised 45 items, which were reduced to 22 items based on patient feedback. The survey data suggested a 13-item scale with four subscales ("patient expertise", "drug effects", "handling drugs" and "exacerbations"). Cronbach's alpha was acceptable for those subscales (>0.7) and for the total score (0.9). Increasing scores on subscales and the total score (implying more unmet needs) showed close and consistent associations with poor asthma control, reduced quality of life and low treatment satisfaction. CONCLUSIONS: The development process of the Needs in Asthma Treatment (NEAT) questionnaire ensured that needs of asthma patient are captured with high validity. The NEAT questionnaire has been shown to be valid, thereby representing a promising tool for research and delivery of patient-centered care.

Physicians' intention to leave direct patient care: an integrative review.

BACKGROUND: In light of the growing shortage of physicians worldwide, the problem of physicians who intend to leave direct patient care has become more acute, particularly in terms of quality of care and health-care costs. METHODS: A literature search was carried out following Cooper's five-stage model for conducting an integrative literature review. Database searches were made in MEDLINE, PsycINFO and Web of Science in May 2014. RESULTS: A total of 17 studies from five countries were identified and the study results synthesized. Measures and percentages of physicians' intention to leave varied between the studies. Variables associated with intention to leave were demographics, with age- and gender-specific findings, family or personal domain, working time and psychosocial working conditions, job-related well-being and other career-related aspects. Gender differences were identified in several risk clusters. Factors such as long working hours and work-family conflict were particularly relevant for female physicians' intention to leave. CONCLUSIONS: Health-care managers and policy-makers should take action to improve physicians' working hours and psychosocial working conditions in order to prevent a high rate of intention to leave and limit the number of physicians actually leaving direct patient care. Further research is needed on gender-specific needs in the workplace, the connection between intention to leave and actually leaving and measures of intention to leave as well as using qualitative methods to gain a deeper understanding and developing validated questionnaires.

The association of effort-reward imbalance and asthma: findings from two cross-sectional studies.

PURPOSE: There is evidence to suggest that work stress is positively associated with the occurrence of asthma. A limitation is that the small number of prior studies utilized unestablished work stress measures, thus constraining interpretation and generalizability. The present study re-examined this association by assessing work stress based on the well-established effort-reward imbalance (ERI) model. METHODS: We drew on data from two cross-sectional studies. Study 1 was conducted in a large pharmaceutical company in 2013 (n = 1,464). Study 2 was based on data from the 2011 wave of the population-based German Socio-Economic Panel (n = 8,388). ERI was assessed by validated questionnaires. Asthma was determined by self-report of a physician-based diagnosis. Associations between ERI or its subcomponents "effort", "reward" and "overcommitment" (z scores or categorized) with asthma were estimated by logistic regression models and reported as adjusted odds ratios (ORs) with 95 % confidence intervals (CIs). RESULTS: A one standard deviation increase of the ERI score (reflecting higher work stress) was associated with a 22-48 % elevated odds of asthma (Study 1: OR 1.48, 95 % CI 1.13-1.95, and Study 2: OR 1.22, 95 % CI 1.10-1.36). Z score-based analyses of the separate ERI components generally suggested moderate associations of effort, reward and overcommitment with asthma in both studies (Study 1: OR effort 1.25, 95 % CI 0.95-1.64, OR reward 0.67, 95 % CI 0.51-0.87, OR overcommitment 1.32, 95 % CI 1.01-1.72; and Study 2: OR effort 1.21, 95 % CI 1.09-1.34, OR reward 0.83, 95 % CI 0.76-0.92, OR overcommitment 1.12, 95 % CI 1.01-1.25). Analyses of categorized exposures largely confirmed these observations. CONCLUSIONS: This is the first study to demonstrate a link between an established work stress measure and asthma. Longitudinal studies are needed to determine the direction of these associations.

Job insecurity is associated with adult asthma in Germany during Europe's recent economic crisis: a prospective cohort study.

BACKGROUND: Job insecurity has been identified as a risk factor for adverse health outcomes. Perceptions of job insecurity steeply increased during Europe's recent economic downturn, which commenced in 2008. The current study assessed whether job insecurity was associated with incident asthma in Germany during this period. METHODS: We used prospective data from the German Socio-Economic Panel for the period 2009-2011 (follow-up rate=77.5%, n=7031). Job insecurity was defined by respondents' ratings of the probability of losing their job within the next 2 years and asthma as self-reports of physician-diagnosed asthma. Associations between job insecurity in 2009 (continuous z-scores or categorised variables) and incident asthma by 2011 were assessed using multivariable Poisson regression. RESULTS: The risk of asthma increased significantly by 24% with every one SD increase of the job insecurity variable. In dichotomised analyses, a probability of job loss of ≥50% (vs <50%) was associated with a 61% excess risk of asthma. A trichotomous categorisation of job insecurity confirmed this finding. CONCLUSIONS: This study has shown, for the first time, that perceived job insecurity may increase the risk of new onset asthma. Further prospective studies may examine the generalisability of our findings and determine the underlying mechanisms.

Self-perceived stress reactivity is an indicator of psychosocial impairment at the workplace.

BACKGROUND: Work related stress is associated with a range of debilitating health outcomes. However, no unanimously accepted assessment tool exists for the early identification of individuals suffering from chronic job stress. The psychological concept of self-perceived stress reactivity refers to the individual disposition of a person to answer stressors with immediate as well as long lasting stress reactions, and it could be a valid indicator of current as well as prospective adverse health outcomes. The aim of this study was to determine the extent to which perceived stress reactivity correlates with various parameters of psychosocial health, cardiovascular risk factors, and parameters of chronic stress and job stress in a sample of middle-aged industrial employees in a so-called "sandwich-position". METHODS: In this cross-sectional study, a total of 174 industrial employees were assessed for psychosocial and biological stress parameters. Differences between groups with high and low stress reactivity were analysed. Logistic regression models were applied to identify which parameters allow to predict perceived high versus low stress reactivity. RESULTS: In our sample various parameters of psychosocial stress like chronic stress and effort-reward imbalance were significantly increased in comparison to the normal population. Compared to employees with perceived low stress reactivity, those with perceived high stress reactivity showed poorer results in health-related complaints, depression, anxiety, sports behaviour, chronic stress, and effort-reward imbalance. The educational status of employees with perceived low stress reactivity is higher. Education, cardiovascular complaints, chronic stress, and effort-reward imbalance were moderate predictors for perceived stress reactivity. However, no relationship was found between stress reactivity and cardiovascular risk factors in our sample. CONCLUSIONS: Job stress is a major burden in a relevant subgroup of industrial employees in a middle management position. Self-perceived stress reactivity seems to be an appropriate concept to identify employees who experience psychosocial stress and associated psychological problems at the workplace.