Workplace Bullying and Violence Might be New, Potentially Modifiable Cardiovascular Risk Factors A multi-cohort study

A European study has revealed that bullying and violence are common at workplaces and those exposed to such stressors are at higher risk of cardiovascular disease (CVD). Psychosocial cardiovascular risk factors such as depression, subclinical depressive symptoms, vital exhaustion, anger, and personality traits such as hostility have been demonstrated as independent predictors of incident cardiovascular disease (CVD). Additionally, social factors associated with increased CVD risk include low socio-economic status, social isolation, low social support, and stress at work or in family life. Psychological and social factors are strongly inter-related and tend to cluster in certain individuals. In the recent most issue of the European Heart Journal, Xu et al. aimed to provide evidence for yet another psychosocial factor involved in CVD risk.

Analyzing data from four Scandinavian cohort studies, the investigators enrolled a total of 79, 201 working men and women hailing from either Sweden or Denmark, aged 18–65 years and free of cardiovascular disease (CVD), defined as the first hospitalization for coronary heart disease or stroke. Self-reporting was used and exposure to workplace bullying and violence were measured at baseline. For the ascertainment of incident CVD including coronary heart disease and cerebrovascular disease, the subjects were linked to national health and death registers. Study-specific results were estimated by marginal structural Cox regression and were combined using fixed-effect meta-analysis.

The results of the study were very interesting. The investigators reported that nine percent were being bullied at work and 13% recorded exposure to workplace violence during the past year. Moreover, a total of 3229 incident CVD cases with a mean follow-up of 12.4 years (765 in the first 4 years) were recorded. After adjustment for age, sex, country of birth, marital status, and educational level, being bullied at work versus those who were not was associated with a hazard ratio (HR) of 1.59 [95% confidence interval (CI) 1.28–1.98] for CVD. Experiencing workplace violence vs. not was associated with a HR of 1.25 (95% CI 1.12–1.40) for CVD. The population attributable risk was 5.0% for workplace bullying and 3.1% for workplace violence. The excess risk remained similar in analyses with different follow-up lengths, cardiovascular risk stratifications, and after additional adjustments. Dose-response relations were observed for both workplace bullying and violence (Ptrend < 0.001). There was only negligible heterogeneity in study-specific estimates.

Therefore, this study was indicative of the fact that workplace bullying and violence might be new, potentially modifiable cardiovascular risk factors. However, despite the impressive number of almost 1 million subject-years and >3000 cases of CVD, the findings needed cautious interpretation and independent replication. Highlighting some key features, the authors pointed out that workplace bullying ‘was mostly of a psychological nature’, and so was the threat of violence. Self-reports of psychological stressors were influenced not only by the nature and intensity of the objective stressor but also by the emotional reaction to it and the psychological state in which the respondent was answering the questionnaire. Hence, the degree of actual misbehavior of people in the environment was not known. Unfortunately, current or previous affect and underlying personality traits were also not reported.

In an accompanying editorial, Dr. Christoph Herrmann-Lingen, Department of Psychosomatic Medicine and Psychotherapy, University of Gottingen Medical Centre, German Centre for Cardiovascular Research (DZHK), Germany, commented, “There is little doubt that prevention of stress-related illness should include the workplace as a potential source of both psychological stress and support. It should address the workplace itself with its economic, physical, and psychological demands, and create a humane environment for individuals and teams. Helping individuals and teams to cope with remaining demands and internal conflicts may reduce bullying and violence and thus increase well-being, health outcomes, and productivity. However, early recognition of untreated, possibly subthreshold, mental disorders that predispose persons to become perpetrators or victims of bullying or violence may additionally be needed in order to facilitate early initiation of appropriate mental health care and interrupt the vicious cycle of workplace bullying or violence, emotional distress, and its behavioral and physiological consequences. Probably this self-reinforcing vicious cycle is more relevant for increased CVD risk than any single psychosocial factor.” Speaking of the role of childhood experiences, he added, “Finally, one should not forget that the basis for personality development, mental disorders, and CVD is laid before persons enter the working environment. Adverse life circumstances in childhood and adolescence lay the ground for interpersonal problems, mental disorders, risk behaviors, and cardiovascular disease in later life. Behavioral interventions for young children from disadvantaged families can lead to better metabolic control in later years, and higher stress resilience in young men may be related to reduced cardiac risk until their mid-50s. It might, therefore, be wise not only to recognize and solve interpersonal problems at the workplace early but also to consider cardiovascular prevention a lifelong endeavor which might best be initiated in much earlier life stages.” Therefore, he stressed those preventive efforts will have to deal with their actual social context, psychological condition, and behavior. This would require awareness of factors that might contribute to elevated risk and an individualized approach to modifying them. Workplace bullying or violence were two factors needing more attention in future CVD prevention programmes. Future observational studies and intervention trials could elaborate on their relative relevance in the broader context of psychosocial CVD risk factors.