1 Service General de Medecine de Contrôle (SGMC), Electricité de France-Gaz de France
2 INSERM U88
3 Department of Psychological Medicine and C-L Psychiatry, Georges Pompidou European Hospital
Correspondence: Anne Chevalier, Service General de Medecine de Contrôle, EDF et Gaz de France, 22/28 Rue Joubert75009 Paris, France. E-mail: anne.chevalier{at}edfgdf.fr
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Abstract |
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Method A case-control study among active employees of the French nationwide power company (Electricité de FranceGaz de France) analysed men aged 3155 years who presented an initial clinical form of ischaemic heart disease from 1993 through 1997, collected from the company registry. These 660 men were each matched by age to 10 controls per case. Adjusted odds ratios (OR) were calculated by logistic regression.
Results There was a significant association between ischaemic heart disease and sick-leave for any medical reason in the 3 years before its onset (OR = 1.79; 95% CI: 1.50, 2.14). This association was strengthened when only absences for depression and anxiety were considered (OR = 3.10; 95% CI: 2.29, 4.19) and remained important and significant when adjusted for socioeconomic status: OR = 2.66 (95% CI: 1.95, 3.63). A previous sick-leave for depression or anxiety in the 10 years before the heart disease strengthened the association (OR = 3.61; 95% CI: 2.39, 4.45), which was further reinforced by an elevated number (4) of such sick-leaves (OR = 5.11; 95 % CI: 3.11, 8.40).
Conclusion Depressive and anxiety disorders that lead to absenteeism seem to be associated with an increased risk of ischaemic heart disease in the 3 years thereafter, especially when depression and anxiety were severe and chronic; this association is independent of socioeconomic status.
Accepted 19 November 2003
Despite a substantial reduction in the mortality they cause, coronary heart diseases (CHD) remain an important public health problem because they generate a significant number of premature deaths. Well-established risk factors such as hypertension, high cholesterol, smoking, diabetes, and lack of physical exercise, do not entirely explain the incidence of CHD.13 Moreover, in all industrialized countries, the incidence of these diseases varies widely with socioeconomic status (SES), and the highest risks are associated with the lowest social status.4 These disparities, which have increased over the past 20 years,5 suggest the possible involvement of occupational factors, in particular, work-related stress and constraints. In the past two decades, researchers have investigated the potential role of psychosocial factors. According to Hemingway and Marmot,6 these include type A behaviour pattern, hostility, depression and anxiety, work-related psychological factors, and (lack of) social support. Several studies have found an association between symptoms of depression or anxiety and subsequent CHD,617 essentially among adults >50 years. These studies have assessed depression and anxiety either by scores on a questionnaire or by a clinical diagnosis, with or without standardized criteria.
Our objectives were to determine if absenteeism for medical causes, especially for depression or anxiety, was associated with the subsequent onset of CHD among middle-aged adults, and to study this link at different SES levels in the French national power company, Electricité de France and Gaz de France (EDF-GDF), which produces and distributes gas and electricity. This company has a workforce of about 140 000 employees in France and provides them with regular medical follow-up, including verification of sick-leaves, throughout their employment. This workforce is distributed across the country and performs a broad range of very diverse jobs. Because its legal status includes a guarantee of employment, the employee population is exceptionally stable. EDF-GDF also has its own medical insurance system, with its own corps of consulting physicians. An important feature of the status of the company is that employees with poor health do not leave the workforce even when absent from work; for severe diseases, specific categories (long term disease and long term disability) exist and such workers are still followed up by the consulting physicians. This point is important because it makes sure that workers do not retire early because of medical problems.
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Methods |
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A CHD registry was constructed from this database. For each death related to heart disease that occurred between 1993 and 1997 and each sick-leave that began during the same period, the consulting physicians were asked to complete a questionnaire that detailed the initial clinical form (severe angina pectoris [AP] attack or myocardial infarction [MI], sudden coronary-related death), its course, with the dates of acute events and death (if it occurred), the examinations on which the diagnosis was based (clinical examination completed by tests such as angiographies, radioisotope scanning, exercise tolerance test, enzyme change), and treatment (fibrinolytics, angioplasty, coronary bypass). Except in cases of sudden death, this information came mainly from hospital reports completed by personal interview during a medical consultation. The medical history of each patient is thus known. The details of the construction of this registry have been reported elsewhere.19 The questionnaires are completed within a few weeks or months of the cardiac event. Only cases of acute CHD are recorded in the registry. After retirement, the company health insurance programme is replaced by the general health insurance system for salaried workers in France, and CHD registration is no longer possible. Consequently, only first AP attacks and first MI diagnosed among active workers, i.e. below the age of 60 (55 for manual workers), could be included in the present study. The incidence rates for MI found among male EDF-GDF workers, assessed from this registry, is close to that for the French male population in the same age range, evaluated from the French MONICA registries (standardized incidence ratio = 113; 95% CI: 0.99, 128.5).19
Design
This investigation was designed as a case-control study. In view of the paucity of cases among women (n = 34), the study was restricted to men. The cases were employees who had initial episodes of CHD that began in the form of MI or AP660 men in all, between 1993 and 1997. The univariate analysis considered separately the subset of 359 MI and the entire set of 660 cases. AP cases were not analysed separately because their diagnosis was based only on clinical criteria. As there was no limitation for the number of controls, we selected 10 controls for each case in order to increase the power of the study (even marginally), matched by 5-year age group, randomly drawn from the entire population of male EDF-GDF employees not included as cases.
Data
Sick-leave
Every year, about 40% of the workforce takes at least one sick-leave that lasts 13 days on average. In 1997, the mean duration of sick-leaves due to psychiatric disorders was 39 days (SD = 55.8), close to that due to depression or anxiety.
Initially we considered only the absences during the 3 years before the year when CHD occurred for each subject. A dichotomous variable (variable No. 1) was constructed: one or more absence for any medical cause (yes/no).
A second variable (variable No. 2) was constructed from the first, with five mutually exclusive categories:
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Social and occupational data
SES was classified according to the French National Institute for Statistics and Economic Studies (INSEE) socio-occupational classification,20 regrouped into four categories (managers and professionals, intermediate white-collar occupations, office workers, and workers). SES was also classified according to the EDF-GDF internal work grade, in three categories (managers, supervisory employees, operating employees), based upon the salary scale and corresponding to level of responsibility, specific job, and seniority; this internal classification may be more precise than the national one.
Analysis
We began with a univariate conditional logistic regression analysis of the association between an initial CHD and each of the three absence variables separately (reference group: those not absent in the 3 years before the cardiac event). A second kind of univariate analysis separately considered work grade (reference: managers) and INSEE SES classification (reference: managers and professionals) as explicative variables.
Next, we used a multivariate conditional logistic regression to estimate the association between CHD and sick-leave, adjusted in each model separately for work grade and for INSEE classification. The interactions between absence variables and SES, measured by work grade or INSEE category, were tested but were not significant in any of the models, and the models taking these interactions into account did not significantly improve those without interactions (models not shown). All analyses were performed with EPICURE software.
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Results |
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We examined severity of depression only in the overall group of cases: the OR for those with 4 absences during the 10-year period was 6.07 (95% CI: 2.72, 9.91). A gradient was observed according to the number of sick-leaves for anxiety or depression: OR = 1.55 (95% CI: 1.1, 12.18) for one sick leave, OR = 2.67 (95% CI: 1.84, 3.89) for two or three (Table 2).
For CHD cases, the univariate analysis of work grade showed a clear SES gradient: compared with managers, supervisory and operating employees had OR of 1.78 (95% CI: 1.38, 2.56) and 2.15 (95% CI: 1.67, 2.76) respectively. Consideration of INSEE SES categories yielded similar results: compared with managers and professionals, intermediate white-collar occupations had an OR of 1.85 (95% CI: 1.48, 2.31), office workers 2.26 (95% CI: 1.54, 3.33), and workers 2.12 (95% CI: 1.62, 2.78).
As these results showed clearly that the OR were similar whether MI or all cases (AP and MI) were considered, the multivariate analysis considered the entire set of cases in order to achieve a better power of the analyses.
Multivariate analysis
As in the univariate analysis, we considered the different sick-leave variables separately. Table 2 shows the OR after adjustment for work grade and for INSEE classification.
After adjustment for work grade, absences for all medical causes remained associated with ischaemic heart disease (OR = 1.58; 95% CI: 1.31, 1.90). This result was identical to that after adjustment for INSEE SES classification (OR = 1.58; 95% CI: 1.31, 1.90) (Table 2). After adjustment for work grade, absence for depression or anxiety also remained associated with ischaemic heart disease (OR = 2.66; 95% CI: 1.95, 3.63). The result is the same after adjustment for INSEE SES category (OR = 2.67; 95% CI: 1.95, 3.66).
In studying recent depression and recurrent and old depression, the reference categories in these models were changed to the supervisory category for work grade and intermediate white-collar occupations for INSEE category, because of the paucity of cases of so-called old depression among managers. After adjustment for work grade, a strong and significant association persisted between recurrent and old depression and CHD (OR = 3.61; 95% CI: 2.39, 5.45). The result was the same after adjustment for INSEE SES category (OR = 3.50; 95% CI: 2.28, 5.36) (Table 2). The OR for recent depression also increased significantly, but to a lesser extent; they were around 2.
Findings for severity of depression or anxiety as measured by the number of sick-leaves for this cause were similar: after adjustment for work grade and for INSEE SES category, the OR for those with 4 sick-leaves for anxiety or depression during the 10 years before occurrence of CHD, remained elevated: 5.11 (95% CI: 3.11, 8.40) and 4.96 (95% CI: 2.98, 8.24) (Table 2).
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Discussion |
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The main limitation of this study is that we did not have information on conventional risk factors, such as hypertension, high cholesterol, smoking, or diabetes. The literature makes it clear that SES is related to ischaemic heart disease22,23 and, moreover, that the main conventional cardiovascular risk factors are strongly related to occupational category.2427 This suggests that these risk factors are the primary mediators of the effect of SES on CHD. Several studies of a subset of 20 000 EDF GDF employees, the GAZEL cohort for which detailed information on various risk factors were collected,28 found a strong social gradient for lifestyle factors.29,30 For example, heavy alcohol consumers account for 17.4% of workers versus 7.9% of managers and professionals. A body mass index >27 is observed in 28.5% of workers and 19.6% of managers and professionals. Other samples of EDF-GDF employees showed a gradient of tobacco consumption according to SES:31,32 about 45% of operating employees were smokers versus 30% of managers and supervisory employees. Thus, our model, adjusted separately for two different markers of SES, controlled SES as a possible confounding factor and therefore also controlled at least partly for the standard cardiovascular risk factors, even if residual confounding cannot be excluded.33 Moreover, the literature shows OR for classic risk factors and CHD on the order of 1.3 to 2.5 in US as well as in European countries.3436 If classic risk factors were the main mediators of the effect of depression on CHD and explained the greatest part of this link, the OR estimated in this study could not be so high and their levels of statistical significance so elevated.
Recent randomized controlled trials that tried to improve cardiac health by acting on depression, such as ENRICHID,37 have generally negative results. As stressed by Singh-Manoux,38 the ineffectiveness of these psychosocial interventions does not mean that psychosocial factors do not play a part of their own in the occurrence and the course of CHD: they are so inextricably associated with social factors that acting on the first without acting on the second could not be efficient.
Several points must nonetheless be considered. First, this study included only men, in view of the small number of women in the company (<20% of the total workforce), and there was a very limited number of incident cases of ischaemic heart disease among them during the observation period (n = 34). While the relationships between depression and anxiety and ischaemic heart disease could be different among women and men, our study strongly suggests that a link exists among men, who experience much higher incidence and mortality rates of ischaemic heart disease than women do.
The data on ischaemic heart disease also present some limitations. The way the registry was constructed gives some confidence in the completeness and accuracy of CHD incident case registration, since an acute episode of ischaemic heart disease always implies at least one sick-leave. Moreover, each potential case was reviewed on a case by case basis by the consulting physician following a strict protocol based on the hospital record (including a full medical history, the results of the examinations on which the diagnosis was established and treatments), completed with a personal interview during a medical consultation, except for sudden deaths.19 However, we could collect only cases that were incident before retirement, i.e. <60 or 55 years old for manual workers, and one might expect a possible bias if people who are at greater risk of CHD leave the company earlier. However, due to the status of the company, employees with poor health do not leave the company, nor retire early because of medical problems. A strong point in favour of a satisfying completeness and accuracy of CHD registration is the fact that the incidence rates for MI among male EDF-GDF workers, assessed from the registry, is close (and even higher), to that for the French male population in the same age range, established from the French MONICA registries (standardized incidence ratio = 113).19
Another potential problem is that our observations of depression and anxiety rely on diagnoses that are coded according to ICD-9 and thus arguable: depression and anxiety are not clearly defined in this classification, and the combination of depressive conditions in the abridged version of ICD-9 that we used to code the sick-leave diagnoses is not necessarily appropriate for an optimal understanding of depression and anxiety in our population. Moreover, these diagnoses were made by company doctors. It is obvious that in such a setting, depression is diagnosed cautiously and indeed perhaps with some reluctance. Furthermore, these physicians, general practitioners by training, probably had some difficulty in recognizing this disease, as other studies have shown.39 Accordingly, we can presume that sick-leaves for depression are quite certainly diagnoses of a well established and not an early or mild depression.
In this study, we considered only cases suffering from a first episode of CHD, i.e. those without any sick-leave for that cause before the cardiac event but we cannot exclude that sub-clinical cardiac disorders existed previously. One explanation of the results of our study could be that these sub-clinical disorders could generate depression or anxiety, leading to absenteeism. We think that this phenomenon is probably limited and cannot explain such strong associations; this is specially true for old depression sick-leaves, taking place years before the onset of CHD. Including psychosomatic disorders in the group of illnesses labelled depression or anxiety could give a substratum to the idea of physical complaints inducing a reporting bias; in fact, sick-leaves for that cause were very few (only three among the cases in the 3 years before CHD) and the same analysis without this diagnosis did not change the results (data not shown).
As stressed by Macleod and Davey Smith,33 issues of bias in recording both acute cardiac events and depression and anxiety sick-leaves and confounding make the evidence of association between absenteeism for depression or anxiety and CHD that we observed in our data, difficult to interpret. Such problems cannot be excluded. However, the results for objectively verified MI alone (after exclusion of AP) were very close to the findings for all CHD cases. In addition, ischaemic heart disease and depression cases were detected through sickness absence, not from personal complaints or hospital admissions: as recording of sick-leaves is compulsory in the company, it is not likely that people who voice their symptoms more could substantially bias the associations we observed. Finally, the absence of interaction between effect of depression and effect of SES suggests that depression and anxiety may play an independent role in the onset of CHD.4044
The validity of these data seems to be better than in most studies in the literature, where scores of depressiveness and not depression were analysed;7,8,11 this may not specifically recognize the presence of a well-established depression. The original feature of our study is the use of absenteeism. It was based upon diagnosed morbidity resulting in sick-leave from work, the diagnosis being established by a physician who examined the subject. The severity of depression or anxiety was assessed by objective variables such as the absence duration and frequency.
The amplification of the association for older depression as well as for severe depression seems particularly interesting. Our results suggest that the chronicity of depressive disorders may play a determinant role in the onset of ischaemic disease, as Barefoot and Schroll have already observed.11 The absence of so-called old depression in the management category was also an interesting finding. It may be related to the well established social inequalities in health care: managers suffering from depression may receive more rapid and better care than those in lower SES categories. Another explanation may be that managers are absent for this reason less often than the other personnel categories,45 either because they seek treatment discreetly without absence from work observable by the social security system or because the taboos related to diagnosis and acknowledgement of depression mentioned above may be stronger for them than for their lower-ranked supervisory and operating colleagues.
Several studies suggest the existence of a web of causation that relates psychosocial factors to CHD. We believe that several different categories of psychosocial factors must be clearly defined, because different types are discussed: some authors analyse mainly the social and psychological conditions at work (decisional attitude, social support at work, psychological burden, imbalance of work and reward, etc. ...), while others look mainly at purely psychological aspects (stress, depression scores, anxiety and depression, type-A psychological profiles). Several studies have examined the relations between these psychosocial factors, in particular, the factors that measure psychological working conditions and depression.4650 They found OR in the order of 1.5. These relations, relatively weak, are unlikely to explain the association between depression and CHD.
Several pathophysiological aspects support the hypothesis of a direct association between these two diseases. One involves the role of serotonin: theories about the mechanisms of depression attribute an important role to this neurotransmitter. Released into the circulation, serotonin may mediate platelet aggregation; it may also induce the release of strong vasoactive substances that can, in people with atherosclerotic lesions, even slight, induce vasoconstriction. The risk of an ischaemic event is thus potentiated.41,51,52 Another pathophysiological process suggested involves periventricular arrhythmia and heart rate variability. The mechanism by which depression might augment the risk of arrhythmia may be associated with increased sympathetic activity or with a vagal-sympathetic imbalance.53 Lastly, the possible effects of some antidepressants must not be forgotten.54
Overall, complex relations seem to link these different factors, markers of mental health and predictors of CHD. Depression and anxiety appear to play a major role in this chain. The objective measure of the outcomes and the strength of the OR observed in our study (in the order of 26) add additional clues towards a causal association between depression and ischaemic heart disease.
The practical consequences of this study may help lead to recommendations for the management of depression. In the current state of research, it may be premature to take depression into account as a risk factor in its own right for ischaemic heart disease, but our findings constitute an additional argument in favour of its role.
KEY MESSAGES
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