Resource-enhancing group intervention against depression at workplace: who benefits? A randomised controlled study with a 7-month follow-up.

OBJECTIVES: The aim of the present study was to investigate whether participation in a structured resource-enhancing group intervention at work would act as primary prevention against depression. The authors analysed whether the intervention resulted in universal, selected or indicated prevention. METHODS: A total of 566 persons participated in a prospective, within-organisation, randomly assigned field experimental study, which consisted of 34 workshops in 17 organisations. The participants filled in a questionnaire, were randomly assigned to either intervention (n=296) or comparison (n=324) groups and returned another questionnaire 7 months later. The intervention, lasting four half-day sessions, was delivered by trainers from occupational health services and human resources. The aim of the structured programme was to enhance participants' career management preparedness by strengthening self-efficacy and inoculation against setbacks. The comparison group received a literature package. The authors measured depressive symptoms using the short version of the Beck Depression Inventory. A high number of depressive symptoms (over 9 points) were used as a proxy for depression. RESULTS: At follow-up, the odds of depression were lower in the intervention group (OR=0.40, 95% CI 0.19 to 0.85) than in the comparison group when adjusted for baseline depressive symptoms, job strain and socio-demographics. In addition, the odds of depression among those with job strain (OR=0.15, 95% CI 0.03-0.81) at baseline were lower after the intervention. The intervention had no statistically significant effect on those with depressive symptoms (over 4 points) at baseline. CONCLUSION: The resource-enhancing group intervention appeared to be successful as universal and selective prevention of potential depression.

Common mental disorders and subsequent work disability: a population-based Health 2000 Study.

BACKGROUND: Work disability due to common mental disorders has increased in Western countries during the past decade. The contribution of depressive, anxiety, and alcohol use disorders to all disability pensions at the population level is not known. METHODS: Epidemiological health data from the Finnish Health 2000 Study, gathered in 2000-2001, was linked to the national register on disability pensions granted due to the ICD-10 diagnoses up to December 2007. Mental health at baseline was assessed using the Composite International Diagnostic Interview (CIDI). Sociodemographic, clinical, and work-related factors, health behaviors, and treatment setting were used as covariates in the logistic regression analyses among the 3164 participants aged 30-58 years. RESULTS: Anxiety, depressive, and comorbid common mental disorders predicted disability pension when adjusted for sex and age. In the fully adjusted multivariate model, comorbid common mental disorders, as well as physical illnesses, age over 45 years, short education, high job strain, and previous long-term sickness absence predicted disability pension. LIMITATIONS: The study population included persons aged 30 or over. Sub groups according to mental disorders were quite small which may have diminished statistical power in some sub groups. Baseline predictors were measured only once and the length of exposure could not be determined. The systems regarding financial compensation to employees differ between countries. CONCLUSIONS: Comorbid mental disorders pose a high risk for disability pension. Other independent predictors of work disability include socio-demographic, clinical, work-related, and treatment factors, but not health behavior. More attention should be paid to work-related factors in order to prevent chronic work disability.

General health and quality-of-life measures in active, recent, and comorbid mental disorders: a population-based health 2000 study.

AIMS: We studied the impact of comorbidity and recency in psychiatric disorders on psychological well-being, perceived health, and quality of life and compared their effect with the effect of a chronic medical condition, type 2 diabetes mellitus. METHODS: Established instruments for psychological distress (12-item General Health Questionnaire [GHQ-12]), self-rated general health, and health-related quality of life (EQ-5D and 15D) were administered for the participants of the nationwide Finnish Health 2000 survey. The diagnoses of depressive, anxiety, and alcohol use disorders and their unique comorbid combinations were based on the Munich version of the Composite International Diagnostic Interview (M-CIDI). RESULTS: People with comorbid anxiety and depressive disorders had the highest distress and lowest health and quality-of-life ratings on all scales. The effects of mental disorders on health-related quality of life and self-rated health were comparable to the effects of diabetes. Type 2 diabetes mellitus and alcohol use disorder were associated with minimal, although statistically significant, increase of psychological distress. Symptom recovery from an active depressive disorder associated with improved well-being on all measures, but residual ill-being was also remarkably common among the partly or fully recovered in all disorder categories. CONCLUSIONS: Even in comparison with a chronic physical illness such as diabetes, comorbid psychiatric disorders have a high impact on psychological well-being, perceived health, and quality of life, when evaluated by simple, useful, and feasible self-rating scales. The scales used may be useful in monitoring the severity and course of psychiatric conditions. Recognizing and treating psychiatric comorbidity is important in improving the quality of life of psychiatric patients.

The association of social support at work and in private life with mental health and antidepressant use: the Health 2000 Study.

BACKGROUND: Social support is assumed to protect mental health, but it is not known whether low social support at work increases the risk of common mental disorders or antidepressant medication. This study, carried out in Finland 2000-2003, examined the associations of low social support at work and in private life with DSM-IV depressive and anxiety disorders and subsequent antidepressant medication. METHODS: Social support was measured with self-assessment scales in a cohort of 3429 employees from a population-based health survey. A 12-month prevalence of depressive or anxiety disorders was examined with the Composite International Diagnostic Interview (CIDI), which encompasses operationalized criteria for DSM-IV diagnoses and allows the estimation of DSM-IV diagnoses for major mental disorders. Purchases of antidepressants in a 3-year follow-up were collected from the nationwide pharmaceutical register of the Social Insurance Institution. RESULTS: Low social support at work and in private life was associated with a 12-month prevalence of depressive or anxiety disorders (adjusted odds ratio 2.02, 95% CI 1.48-2.82 for supervisory support, 1.65, 95% CI 1.05-2.59 for colleague support, and 1.62, 95% CI 1.12-2.36 for private life support). Work-related social support was also associated with subsequent antidepressant use. LIMITATIONS: This study used a cross-sectional analysis of DSM-IV mental disorders. The use of purchases of antidepressant as an indicator of depressive and anxiety disorders can result in an underestimation of the actual mental disorders. CONCLUSIONS: Low social support, both at work and in private life, is associated with DSM-IV mental disorders, and low social support at work is also a risk factor for mental disorders treated with antidepressant medication.

Overcrowding in hospital wards as a predictor of antidepressant treatment among hospital staff.

OBJECTIVE: This report assessed whether hospital ward overcrowding predicts antidepressant use among hospital staff. METHOD: The extent of hospital ward overcrowding was determined using administrative records of monthly bed occupancy rates between 2000 and 2004 in 203 somatic illness wards in 16 Finnish hospitals providing specialized health care. Information on job contracts for personnel was obtained from the employers' registers. Comprehensive daily data on purchased antidepressant prescriptions (World Health Organization's Anatomical Therapeutic Chemical classification code N06A) for nurses (N=6,699) and physicians (N=641) was derived from national registers. Cox proportional hazards models were used to examine the association between bed occupancy rate and subsequent antidepressant treatment. Monthly bed occupancy rates were used as a time-dependent exposure that could change in value over the course of observation. Hazard ratios were adjusted for sex, age, occupation, type and length of employment contract, hospital district, specialty, and calendar year. RESULTS: Exposure over 6 months to an average bed occupancy rate over 10% in excess of the recommended limit was associated with new antidepressant treatment. This association followed a dose-response pattern, with increasing bed occupancy associated with an increasing likelihood of antidepressant use. There was no evidence of reverse causality; antidepressant treatment among employees did not predict subsequent excess bed occupancy. CONCLUSIONS: The increased risk of antidepressant use observed in this study suggests that overcrowding in hospital wards may have an adverse effect on the mental health of staff.

Occupational burnout and medically certified sickness absence: a population-based study of Finnish employees.

OBJECTIVE: Occupational burnout is a common problem in working populations, but its association with sickness absence is poorly understood. The contribution of occupational burnout to medically certified sickness absence was examined in a population-based sample of employees. METHODS: A representative sample of 3151 Finnish employees aged 30-60 years participated in a comprehensive health study in 2000-2001, including an assessment of physician-diagnosed physical illnesses and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders based on the Composite International Diagnostic Interview. Burnout was measured with the Maslach Burnout Inventory-General Survey. Sickness absences longer than 9 days in 2000-2001 were extracted from a register of the Social Insurance Institution of Finland. RESULTS: The occurrence of medically certified sickness absence was more prevalent among employees with burnout than among those without burnout. After adjusting for sociodemographic factors and mental and physical disorders, the odds ratio of sickness absence for severe burnout was 6.9 [95% confidence interval (95% CI)=2.7-17.8] for men and 2.1 (95% CI=1.1-4.0) for women. Among employees with mental or physical disorders, severe burnout was associated with a 7.7-fold risk of sickness absence among men and with a 2.6-fold risk among women. The duration of absence was related to burnout among men with absences, for whom severe burnout accounted for 52 excess sickness absence days during the 2-year period after adjusting for sociodemographic factors, mental disorders, and physical illnesses. CONCLUSIONS: Severe burnout is associated with a substantial excess risk of medically certified sickness absence among both men and women. This association is independent of prevalent mental disorders and physical illnesses.

Temporary employment and antidepressant medication: a register linkage study.

Evidence on the association between temporary employment and mental health is mixed. This study examined associations of temporary employment with register-based antidepressant medication by type and length of temporary job contract and socioeconomic position. Antidepressant prescriptions (1998-2002) were linked to register data for 17,071 men and 48,137 women in 10 Finnish municipalities. Repeated measures analyses over time were adjusted for age, socioeconomic position, and calendar year. After adjustments, temporary employment with a job contract more than 6 months was associated with odds ratio (OR) of 1.18 (95% confidence interval CI 1.03-1.37) for antidepressant use in men and 0.99 (0.93-1.06) in women. Among temporary employees with a job contract of 6 months or less the corresponding odds ratio was higher (OR 1.43, 95% CI 1.19-1.73 in men, OR 1.18, 95% CI 1.09-1.28 in women). Long-term unemployed who were in short-term government-subsidised temporary employment had the highest odds of antidepressant use (OR 1.57, 95% CI 1.23-2.02 in men, OR 1.38, 95% CI 1.20-1.59 in women). During the study period, increase in the prevalence of antidepressant medication was more rapid among women in government-subsidised temporary employment than among permanently employed women. Among men, the association between temporary employment and antidepressant use was stronger within lower grade occupations. The results suggest that using antidepressants is more pronounced when temporary employment is unstable.

Quality of treatment and disability compensation in depression: comparison of 2 nationally representative samples with a 10-year interval in Finland.

OBJECTIVE: Depressive disorders cause substantial work impairment that can lead to disability compensation. The authors compared treatment received for depression preceding disability pension between 2 nationally representative samples with a 10-year interval. METHOD: The medical statements for 2 random samples drawn from the Finnish national disability pension registers, representing populations granted a disability pension for DSM-III-R major depression during a 12-month period from October 1993 through September 1994 (N = 277) and for ICD-10 depressive disorders (F32-F33) from October 2003 through September 2004 (N = 265) were examined. The proportions of persons receiving weekly psychotherapy, antidepressants, adequate antidepressant dosage, sequential antidepressant trials, lithium augmentation, and electroconvulsive therapy (ECT) were compared. RESULTS: No significant differences emerged between the 2 samples, except for the adequacy of antidepressant dosage. Few subjects in either of the samples (8.7% for 1993-1994 vs. 10.6% for 2003-2004, p = .45) had received weekly psychotherapy. Most had received antidepressants (87.4% vs. 85.6%, p = .55) with increasingly adequate dosage (75.6% vs. 85.0%, p = .02), but only a minority had received sequential antidepressant trials (39.5% vs. 44.5%, p = .24). Lithium augmentation and ECT were rare (1.1% vs. 1.5%, p = .66 and 4.0% vs. 1.5%, p = .08, respectively). Even in 2003-2004, over half of the subjects were granted a disability pension without sequential antidepressant trials. CONCLUSION: This nationally representative study indicates that, despite an increased antidepressant use and improved practice guidelines for depression, a considerable proportion of the people granted long-term compensation for depression seem to be suboptimally treated. Given the enormous costs of the disability, attention to the quality of treatment provided for depression is warranted before long-term disability compensations are granted.

Interventions in relation to occupational burnout: the population-based health 2000 study.

OBJECTIVE: To study participation in occupational and individual-focused interventions in relation to burnout. METHODS: We used data from a questionnaire, structured interview, national register of psychopharmacological prescriptions, and the Composite International Diagnostic Interview in a nationally representative Finnish sample of 3276 employees (30 to 64 years). RESULTS: When compared with employees free of burnout, the odds ratio of severe burnout for participation in occupational interventions was 0.41 (95% confidence interval [CI] = 0.26 to 0.65) and in individual-focused interventions 5.36 (95% CI = 3.14 to 9.17). Antidepressant prescriptions were 2.53 (95% CI = 1.04 to 6.15) times more common among those with severe burnout than among those without burnout after adjustment for depressive and anxiety disorders. CONCLUSIONS: Employees with burnout were less often targets of occupational interventions but participated more in individual-focused interventions when compared with other employees. The use of antidepressants among employees with severe burnout was not fully explained by coexisting depressive or anxiety disorders.

Job strain and psychologic distress influence on sickness absence among Finnish employees.

BACKGROUND: Work stress is a recognized risk factor for mental health disorders, but it is not known whether work stress is associated with the morbidity among individuals with psychologic distress. Another shortcoming in earlier research is related to common method bias-the use of individual perceptions of both work stress and psychologic distress. This prospective study was assessed using the General Health Questionnaire (GHQ-12), which identified psychologic distress as a predictor of sickness absence and the effect of work-unit measures of job strain on sickness absence among cases. METHODS: Survey data were collected on work stress, indicated by high job strain, for a cohort of public sector employees (6,663 women, 1,323 men), aged 18 to 62 at baseline in 2000-2002, identified as GHQ-12 cases. Coworker assessments of job strain were used to control for bias due to response style. A 2-year follow-up included recorded long-term (>7 days) medically certified sickness absence. Adjustments were made for age, socioeconomic position, baseline chronic physical disease, smoking, and heavy alcohol consumption. RESULTS: Cases with psychologic distress had 1.3 to 1.4 times higher incidence of long-term sickness absence than non cases. Among cases, high job strain predicted sickness absence (hazard ratio 1.17 in women, 1.41 in men). The significant effect of job strain on sickness absence was found among workers in high socioeconomic positions (hazard ratio 1.54 for women, 1.58 for men) but not among employees in low socioeconomic positions (hazard ratio 1.06 for women, 1.31 for men). CONCLUSIONS: Psychologic distress has an independent effect on medically certified sickness absence. The identification of employees with high job strain and the improvement of their working conditions should be considered as an important target in the prevention of adverse consequences of psychologic distress.

Alexithymia and occupational burnout are strongly associated in working population.

OBJECTIVE: The relationship between alexithymia and occupational burnout has not previously been studied. We investigated the association between alexithymia and occupational burnout in a representative nationwide population health study. METHODS: This study was a part of the Finnish Health 2000 Study. The nationally representative sample comprised 3322 employees aged 30-64 years. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20) and occupational burnout with the Maslach Burnout Inventory-General Survey. Sociodemographic and health-related variables including depression were treated as confounders in the logistic regression analyses, which were performed alternately with TAS-20 total score and the scores of the three TAS-20 factor scales as alexithymia variables. RESULTS: Alexithymia and its three facets were significantly associated with occupational burnout even when controlled for confounding factors. CONCLUSIONS: Even though both alexithymia and depression are associated with burnout, alexithymia may be an independent risk factor for occupational burnout.

Employment predictors for discharged schizophrenia patients.

OBJECTIVE: To investigate predictors for competitive employment in a three-year follow-up study of discharged schizophrenia patients. METHODS: The nationally representative sample comprised 2168 schizophrenia patients aged 15-64 years, who had been discharged from psychiatric hospitals in 1986, 1990, and 1994 in Finland. Comprehensive data were collected from psychiatric case records on the patients' sociodemographic and clinical characteristics at discharge and use of services during the follow-up period. The patients were interviewed 3 years after discharge using a structured interview schedule, which included questions on employment. RESULTS: At follow-up, the competitive employment rate declined among the three cohorts (1989: 7.4%, 1993: 2.6% and 1997: 1.5%), whereas the rate of non-competitive employment remained at the same level (8.4%, 7.2% and 9.6%). The probability of competitive employment was higher for those who, at the time of discharge, were not on disability pension and had a current or past history of marriage, and had been discharged in the late 1980s. The probability of being competitively employed was lower for those who had no occupation at discharge and for those who had spent more time in hospital care during the three years after discharge. CONCLUSIONS: The high unemployment rate and continuous changes in work life, which characterized Finland in the 1990s may have negatively affected the employment prospects of schizophrenia patients. Work rehabilitation should be more commonly offered, to increase their opportunities for obtaining competitive employment and for improving their quality of life.

The effect of pre-employment factors on job control, job strain and psychological distress: a 31-year longitudinal study.

This study examined the role of pre-employment factors, such as maternal antenatal depression, low birth weight, childhood socioeconomic position, early adolescence health risk behaviours and academic performance, in the relationship between work characteristics (low job control and high job demands, or job strain) and psychological distress at age 31. The data of 2062 women and 2231 men was derived from the prospective unselected population-based Northern Finland 1966 Birth Cohort study. Results of linear regression models showed that being female, father's low socioeconomic position, and poor academic achievement in adolescence were linked to low control and high job strain jobs at age 31, and that low control and high job strain were associated with psychological distress at age 31. Although having lower school grades, high absence rate from school, and moderate alcohol consumption at age 14 were significant predictors of psychological distress at age 31, the associations between job control, job strain and psychological distress remained after controlling for these and other pre-employment effects. As such, pre-employment factors do seem to link people to risky work environments, which in turn seem to relate strongly to psychological distress. However, the relationship between pre-employment factors and later psychological distress in adulthood is not completely explained by job environment.

Employment status, mental disorders and service use in the working age population.

OBJECTIVES: This study examined the association between employment status and specific DSM-IV (Diagnostic and Statistical Manual for Mental Disorders, IVth edition) depressive, anxiety and alcohol use disorders and the association between employment status and service use for these disorders. METHODS: As part of the representative population-based "Health 2000 Study" of Finns aged 30 years or over, 3440 employed, 429 unemployed, and 820 economically inactive persons of working age (30-64 years) participated in a comprehensive health examination, including the standardized Composite International Diagnostic Interview. RESULTS: The risk of mental disorders was generally higher among the unemployed and the economically inactive than among the employed. The respective odds ratios were 1.79 [95% confidence interval (95% CI) 1.26-2.54] and 1.54 (95% CI 1.06-2.25) for depressive disorders, 2.68 (95% CI 1.85-3.89) and 2.53 (95% CI 1.76-3.65) for anxiety disorders, and 2.58 (95% CI 1.82-3.65) and 1.43 (95% CI 0.91-2.22) for alcohol use disorders. Similar results were obtained for most of the specific categories of these disorders. Among the persons with anxiety disorders, the odds for treatment contact were 2.35 (95% CI 1.06-5.23) times higher for the unemployed than for the employed after control for disorder severity. For those with an alcohol use disorder, the corresponding odds ratio was 3.51 (95% CI 1.23-9.98). CONCLUSIONS: Common mental disorders are less prevalent among the employed than among unemployed and economically inactive people. Among those with anxiety or alcohol use disorders, service use is less common among the employed than among the unemployed. This difference is not explained by the severity of the clinical state.

Organisational downsizing and increased use of psychotropic drugs among employees who remain in employment.

OBJECTIVE: Organisational downsizing is common in modern work life, but its effect on employees' mental health is not known. The authors examined whether working in downsizing organisations predicts use of psychotropic drugs among employees who remain in employment. DESIGN, SETTING AND PARTICIPANTS: Prospective cohort study of municipal employees in Finland. 4783 employees worked in downsized units but kept their jobs after downsizing in 1993, 4271 employees lost their jobs during the downsizing, and 17 599 employees did not experience downsizing. The outcome was psychotropic drug prescriptions (antidepressants, anxiolytics and hypnotics) during 1994-2000 extracted from nationwide registers and linked to the data by means of each participant's personal identification number. MAIN RESULTS: After adjustment for predownsizing characteristics, employees who were exposed to downsizing but kept their jobs were at a higher risk of being prescribed psychotropic drugs (rate ratio 1.49, 95% CI 1.10 to 2.02 in men and 1.12, 95% CI 1.00 to 1.27 in women) than those not exposed to downsizing. The association of downsizing was strongest with hypnotics among the men and with anxiolytics among the women. An increased rate of psychotropic prescriptions after downsizing was also seen in male workers who lost their job (rate ratio 1.64, 95% CI 1.19 to 2.25). CONCLUSIONS: The association between organisational downsizing and increased use of psychotropic drugs suggests that this managerial strategy may pose mental health risks among employees.

Work stress, mental health and antidepressant medication findings from the Health 2000 Study.

BACKGROUND: Population-based studies on the association between work stress and mental disorders are scarce, and it is not known whether work stress predicts mental disorders requiring treatment. AIMS: To examine the associations of work stress with DSM-IV mental disorders and subsequent antidepressant medication. METHODS: 3366 participants from a representative sample of the Finnish working population responded to a survey (The Health 2000 Study). 12-month prevalence of depressive or anxiety disorders was examined with the Composite International Diagnostic Interview. Data on antidepressant prescriptions with a 3-year follow-up period were collected from a nationwide register of Social Insurance Institution. RESULTS: In men and women, high job demands, low job control and high job strain were associated with 12-month prevalence of depressive or anxiety disorders. After adjustment for lifetime and baseline mental disorders, men with high job demands and high job strain had increased risk of future antidepressant medication. CONCLUSIONS: Work stress is associated with mental disorders among both sexes and among men it is a risk factor for mental disorders treated with antidepressant medication.

Body mass index and functioning in long-term schizophrenia. Results of the DSP project.

OBJECTIVE: The study evaluates the association of body mass index (BMI) with functioning in male and female patients with long-term schizophrenia. METHOD: 722 long-term schizophrenia patients were interviewed three years after discharge from hospital. Their weight and height were recorded and data on their background, illness history, psychosocial functioning (Global Assessment Scale; GAS), health behaviour, daily doses of neuroleptics, and psychiatric symptoms were collected. RESULTS: BMI correlated significantly with GAS scores in male (r=0.202, p=0.000) but not in female patients. In male patients, BMI associated significantly (p=0.005) with GAS scores even when the effects of psychiatric symptoms and other confounding variables were taken into account. CONCLUSIONS: In male but not in female long-term patients with schizophrenia, low BMI associates with poor functioning. It is suggested that among male schizophrenia patients, low BMI may be an indicator of poor functioning.

Contribution of burnout to the association between job strain and depression: the health 2000 study.

OBJECTIVE: The objective of this study was to investigate the contribution of burnout to the association between job strain and depression. METHODS: A representative sample of 3270 Finnish employees aged 30 to 64 years responded to the Maslach Burnout Inventory-General Survey and the Beck Depression Inventory and participated in the Composite International Diagnostic Interview. RESULTS: High strain compared with low strain was associated with 7.4 (95% confidence interval [CI] = 5.6-9.7) times higher odds of burnout, 3.8 (95% CI = 2.8-5.1) times higher odds of depressive symptoms, and 1.7 (95% CI = 1.1-2.6) times higher odds of depressive disorders. The risk for depressive symptoms and for depressive disorders of high strain was reduced by 69% or more after adjusting for burnout. CONCLUSION: Burnout is strongly related to job strain and may in part mediate the association between job strain and depression.

Alcohol dependence in relation to burnout among the Finnish working population.

AIMS: To investigate the relationship of burnout to alcohol dependence and high alcohol consumption. DESIGN: A cross-sectional population-based multi-disciplinary 'Health 2000 Study'. The analyses were performed separately for the women and the men and adjusted for socio-demographic factors. SETTING AND PARTICIPANTS: In Finland, 3276 active employees (1637 women and 1639 men), aged 30-64 years, from a representative population sample. MEASUREMENTS: The diagnosis of Diagnostic and Statistical Manual of Mental Disorders version IV (DSM-IV) alcohol dependence was based on the standardized Munich Composite International Diagnostic Interview (M-CIDI). The assessment of high alcohol consumption was based on self-reported alcohol use. Burnout was assessed with the Maslach Burnout Inventory-General Survey (MBI-GS). FINDINGS: The 12-month prevalence of alcohol dependence was associated with burnout among both men and women. Each one-point increase in burnout score was associated with an 80% increase in the incidence for alcohol dependence among women and a 51% increase among men. These associations persisted when socio-demographic factors were adjusted. The associations between burnout and high alcohol consumption were not statistically significant. CONCLUSIONS: There is an association between burnout and alcohol dependence among both genders. Among both women and men, attention to alcohol-related behaviour is warranted in the clinical context when burnout and other problems related to work are encountered. Interventions which include assessment of work conditions and management of work-related stress should be targeted at employees with alcohol dependence in addition to traditional treatment.