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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790XOn-line version ISSN 1980-5497

Rev. bras. epidemiol. vol.18 no.4 São Paulo Out./Dec. 2015 

Original Articles

Sickness absence due to mental disorders and psychosocial stressors at work

João Silvestre Silva-JuniorI  II 

Frida Marina FischerII 

INational Social Security Institute, Ministry of Social Security - São Paulo (SP), Brazil.

IIDepartment of Environmental Health, School of Public Health, Universidade de São Paulo - São Paulo (SP), Brazil.



Mental disorders are the third leading cause of social security benefit due to sickness in Brazil. Occupational exposure to psychosocial stressors can affect the workers' mental health. The social security medical experts are responsible for characterizing if those sicknesses are work-related.


To evaluate the factors associated with sick leave due to mental disorders, in particular, the perception of workers on psychosocial factors at work.


This is an analytical study carried out in São Paulo, Brazil, with 131 applicants for sickness benefit due to mental disorders. Questionnaires were applied to assess the sociodemographic data, habits/lifestyle information, and perceived psychosocial factors at work.


The most common diagnosis was depressive disorders (40.4%). The medical experts considered 23.7% of all applications as work-related. Most of the participants were female (68.7%), up to 40 years of age (73.3%), married/common-law marriage (51.1%), with educational level greater than or equal to 11 years (80.2%), nonsmokers (80.9%), not alcohol consumers (84%), and practice of physical activities (77.9%). Regarding psychosocial factors, most of the participants informed a high job strain (56.5%), low social support (52.7%), effort-reward imbalance (55.7%), and high overcommitment (87.0%). There was no statistical association between the work-related mental disorders sickness benefits and independent variables.


The concession of social security sickness benefits is not associated with sociodemographic data, habits/lifestyle, or psychosocial factors at work. Occupational exposure to unfavorable psychosocial factors was reported by most workers on sick leave due to mental disorders. However, several cases were not recognized by the social security medical experts as work-related, which may have influenced the results of the associations.

Keywords: Mental disorders; Absenteeism; Social security; Stress; psychological; Occupational health; Mental health.



Os transtornos mentais são a terceira principal causa de concessão de benefício previdenciário por incapacidade no Brasil. A exposição ocupacional a estressores psicossociais pode comprometer a saúde mental dos trabalhadores. Cabe ao perito médico previdenciário caracterizar se o adoecimento incapacitante está relacionado com as condições de trabalho.


Avaliar os fatores associados ao afastamento do trabalho por transtornos mentais relacionados ao trabalho, em especial a percepção dos trabalhadores sobre fatores psicossociais no trabalho.


Estudo analítico realizado em São Paulo com 131 requerentes de auxílio-doença por transtornos mentais. Foram preenchidos questionários sociodemográfico, de hábitos/estilo de vida e fatores psicossociais no trabalho.


Os quadros mais frequentes foram transtornos depressivos (40,4%). Entre todos os requerimentos, 23,7% foram considerados relacionados ao trabalho. O perfil da maioria dos participantes era: sexo feminino (68,7%), até 40 anos de idade (73,3%), casado/união estável (51,1%), escolaridade igual ou superior a 11 anos (80,2%), não tabagista (80,9%), não ingeria bebida alcoólica (84%), fazia atividade física (77,9%). Sobre os fatores psicossociais, prevaleceu trabalho de alta exigência (56,5%), baixo apoio social (52,7%), desequilíbrio esforço-recompensa (55,7%) e comprometimento excessivo (87,0%). Não houve associação estatística entre casos de transtornos mentais relacionados ao trabalho e as variáveis independentes. Conclusão: A concessão do benefício auxílio-doença acidentário não foi associada a variáveis sóciodemográficas, hábitos/estilo de vida ou fatores psicossociais no trabalho. A exposição ocupacional a estressores psicossociais esteve presente no relato da maioria dos trabalhadores afastados do trabalho por transtornos mentais. Entretanto, diversos casos não foram reconhecidos pela perícia médica previdenciária como relacionados ao trabalho, o que pode ter influenciado nos resultados das associações.

Palavras-chave: Transtornos mentais; Absenteísmo; Previdência social; Estresse psicológico; Saúde do trabalhador; Saúde mental.


Mental and behavioral disorders are important causes of work absences. Those conditions are frequent and commonly disabling, evolving to sickness absenteeism and reduction of work productivity1. In Brazil, mental disorders are the third main cause of granting social security sickness benefits due to work disability. Over 203,000 new benefits were granted in each year between 2008 and 2011, and 6.25% of them was considered by the social experts as work-related2.

A joint publication of the International Labor Organization (ILO) and the World Health Organization (WHO) drew the attention to the relevance of the relation between psychosocial factors at work and the consequences on workers´ health. Chronic exposure conditions and adverse psychosocial stressors at work are associated with psychosomatic complaints, psychiatric symptoms, and changes in the well-being of individuals3.

Theoretical models were developed in order to define and explain the effects of occupational stress on the workers´ health. The demand-control-social support (DCS) model4 5 studies the relation between the psychological demands at work and the decision latitude of workers, mediated by the social support from colleagues and supervisors. Another model is the effort-reward imbalance (ERI) 6, which evaluates the perception of the worker regarding the efforts at work and the rewards resulting from these efforts, mediated by an excessive personal commitment to work. Recent studies about workers sick leave have used both models as methods to investigate the association with psychosocial factors at work7 8 9 10 11 12.

Difficulties to identify the causal relationship between mental illness and occupational stressors occur due to the lack of standardization of a protocol approaching several risk factors13. In Brazilian social security system, the legal criteria for characterizing the benefit as work-related - when there is a relation between the disabling illness and work conditions - are determined by the use of the social security technical nexus. The medical experts of the National Social Security Institute (Instituto Nacional do Seguro Social - INSS) have the competence to analyze the plausibility of the relation between environment/work conditions as the cause or the associate cause of a disabling sickness. The characterization of the sickness benefit as work-related (known as B91) is a result of three possibilities14:

  1. 1. Professional technical nexus: on the basis of the association between pathologies and occupational exposure, according to the professional scope of the insured worker, described in the lists A and B of Annex II, Decree No. 3.048/9914;

  2. 2. Individual technical nexus: due to injuries at work or during commuting time, occupational accidents and special conditions in which the work is carried out and directly related to these conditions, in the terms of the § 2nd art. 20 of Law No. 8.213/9115;

  3. 3. Epidemiological technical nexus (Nexo Técnico Epidemiológico Previdenciário - NTEP): applicable when there is a statistical significance in the association between disabling sickness (according to the International Statistical Classification of Diseases and Health Related Problems, 10th version - ICD-10) and the economic activity of the company (according to the National Classification of Economic Activities - CNAE) to which the insured is bound to. These relations are set out at the List C of Annex II, Decree No. 3.048/9914, modified by the Decree No. 6.042/200716.

This study aims to evaluate the factors associated with sickness absence due to mental disorders which the medical experts considered work-related. As a second aim, to evaluate the perception of workers about the exposure to psychosocial factors at work described in DCS and ERI models.


This cross-sectional analytical study was carried out in a Social Security Agency (Agência da Previdência Social - APS) of the Brazilian National Social Security Institute (INSS) located in the central region of the city of São Paulo. The participants of the study were workers who requested sickness benefit and were selected randomly. The group of patients scheduled for each medical expert to proceed the evaluation was considered as a cluster. Between June and August 2011, the clusters were selected daily and randomly with the objective of composing the group to be studied. After the conclusion of the benefit evaluation, the participants who met the inclusion criteria were referred for an interview with one of the researchers. The participants should have a formal employment and should be claiming the sickness benefit due to sick leave for more than 15 days. The participants who had more than one job or those who were in sick leave for more than 12 months were excluded from this study.

In order to calculate the size of the sample for a reliable estimate on the proportion in an unlimited population, it was considered a confidence level of 95% (α < 0.05), maximum estimation error of 5%, and outcome proportion in the population of 6.25%2. The minimum sample would be 90 participants, but 131 workers agreed to take part in this study.

Interviews were conducted in order to fill out the questionnaire with information about gender (male; female), age range (less than 40 years of age; equal or more than 40 years of age), marital status (married/stable union; others), education (less than 11 years of study; equal or more than 11 years of study), smoking habits (yes; no), regular alcohol consumption (yes; no), and practice of physical activity within the last month (yes; no).

The psychosocial factors at work described in DCS model were analyzed using the validation for Brazilian Portuguese of the Swedish Demand-Control-Support Questionnaire (DCSQ), previously known as the Job Stress Scale17. Its analysis allows the work conditions to be classified according to the quarters built from the relation between demand and control: active work, passive work, low strain, and high strain ("job strain"). The questionnaire is also used in order to categorize social support into high or low.

The psychosocial factors at work described in ERI model were evaluated from the validation into Brazilian Portuguese of the Effort-Reward Imbalance Questionnaire (ERI-Q)18. When the resulted index between effort and reward was higher than 1.0 (one), it characterized imbalance. The questions on work overcommitment allowed categorizing this condition into high or low.

Data from the medical expert reports issued by the INSS on the same day of data collection were analyzed in order to verify the diagnosis indicated by the physician the cause of work disability. The code for this disabling illness should be part of Chapter V of the ICD-10 and compatible with "mental or behavioral disorder". Moreover, information on the possibility of characterization of the technical nexus of the social security between disabling illness and work conditions was collected, in order to determine the work-related sickness benefit (B91).

Statistical analysis between the kind of social benefit - work-related or non-work-related - and the independent variables was performed using the χ2 and Fisher's exact tests. The statistical significance was considered when the p-value was lower than 0.05. EpiData software, version 3.1, was used for the database organization; data were analyzed using the Epi Info(tm) software, version

All the participants signed the informed consent according to the Declaration of Helsinki. The research was authorized by the INSS for data collection and allowed access to the medical experts' reports. The study was approved by the Research Ethics Committee of the School of Public Health of the University of São Paulo (Endorsement No. 027/2011).


The most common mental conditions were depressive episodes (ICD-10 F32), representing 40.4%, followed by other anxiety disorders (ICD-10 F41), with 19.8% (Table 1).

Table 1: Distribution of the participants according to the ICD-10* and description of the diagnosis established in the social security medical report, São Paulo, Brazil, 2011 (n = 131). 

*ICD-10: International Classification of Diseases Statistic and problems related to health, 10th review.

Most participants were females (68.7%), less than 40 years of age (73.3%), married or in a stable relationship (51.1%), and with school education equal or higher than 11 years of study (80.2%). Regarding the habits and lifestyle, most of them were nonsmokers (80.9%), did not drink alcohol regularly (84.0%), and practiced physical activities (77.9%) (Table 2).

Table 2: Distribution of the participants according to the sociodemographic data, habits and lifestyle, and perception of exposure to psychosocial factors at work, São Paulo, Brazil, 2011 (n = 131). 

WR MBD: Work-related mental and behavioral disorders; ERI: effort-reward imbalance.

In relation to the occupational stress models, the most often listed psychosocial factors were: the perception of being in a high strain job i.e., with high demands and low control (56.5%); experiencing low social support (52.7%); the ERI condition i.e., having to exert high efforts but with low rewards (55.7%) and high overcommitment (87.0%) (Table 2).

The mental disorders were considered as work-related in 23.7% of the cases following the analyses performed by the social security medical experts. There was not a significant association between granting sickness benefits due to mental and behavioral disorders related to work and the sociodemographic, habits/lifestyle or psychosocial factors at work variables, including those which represent risky conditions for the workers health (Table 2).


The similar distribution of unfavorable psychosocial factors at work among the groups suggests that the social security tools do not take into consideration the presence of those negative work conditions to evaluate the technical nexus between disabling sickness and work. Probably, workers who suffered from occupational exposure to such stressors did not have their benefit characterized as work-related due to difficulties of the medical experts into recognizing that unfavorable psychosocial aspects of work may contribute to disabling illness.

On completion of receiving the work-related sickness benefit payment, all workers employed in formal jobs have the right to remain at their jobs being their employment secured for a minimum period of time of 12 months15. In addition to that, during the sick leave, the contribution for the unemployment fund program (Fundo de Garantia do Tempo de Serviço - FGTS) should be kept19. Therefore, it is crucial that medical experts characterize the association of the so-called "technical nexus with work" when granting the benefit due to work disability in order to ensure the worker such labor rights.

The participants of this study reported a perception of frequent high strain jobs, according to the DCS model. Such high-demand and low-control situations are described as risk factors for sickness absence, in general8 and for long-term sick leave due to mental disorders20. Besides, when there are work conditions with high demands and low social support, known as "isostrain", there is an increased probability of long absenteeism due to mental illness when compared with other conditions12.

The ERI is associate with long-term absenteeism7 and the high overcommitment is a risk factor for depression21 and for sickness absence8. The interaction between the three dimensions of the ERI model increases the chance of long-term sick leaves from work due to mental disorders12. However, despite the great majority of participants of the present study reported imbalance between efforts and rewards at work the psychosocial factors did not show a significant association with the work-related social security benefit.

Assessment protocols for psychosocial risks may contribute to the improvement of evaluations during social security medical expert routine. For example, it can be mentioned the NTEP, which established relations between mental disorders and various economic branches14. By considering that several situations of technical nexus observed by the experts were not supported by the scientific literature regarding the occupational health literature22, the use of DCS/ERI questionnaires could help those professionals to perform a more accurate evaluation of the cases.

Routinely, the requests for sickness benefit in which the social security system indicated NTEP are not characterized by the experts23. The lack of objective criteria to deny the relation between illness and work conditions may harm workers who are entitled to a work-related benefit. Underreporting the diseases associated with work also limits the knowledge of the real extent of the problem and may impair the development of policies to promote and to protect workers´ health. Therefore, it is important that the medical experts conduct inspections at workplace before deny or confirm the technical nexus between disabling illness and occupational aspects22.

  • • The limitations and novelties presented by this study are:

  • • the findings are restricted to a group of urban workers evaluated in the southeastern region of Brazil;

  • • the process of random sampling tried to avoid the possible biases in the selection;

  • • the diagnosis and definition of outcomes were characterized by social security medical experts, minimizing measurement biases; and

  • • recalls biases were probably reduced when establishing the maximum period of absence from work. However, interviewing individuals in poor mental health conditions may interfere in their perception of exposure factors20.


In this study, we concluded that the occupational exposure to adverse psychosocial factors at work has been present in most reports from workers in long-term sickness absence due to mental disorders. However, there was not a significant association between the granting of work-related sickness benefits and the perception of exposure to psychosocial occupational stressors or other independent variables studied. Maybe the tools used by the social security system are not suitable to evaluate the impacts of negative psychosocial factors at work in mental health of the studied sample population.

The correct evaluation of psychosocial stressors at work presents conceptual and methodological difficulties. It is not simple to recognize them, or there might be an undervaluation of such risk factors. The use of validated methods and tools are strategies, which may assist the medical experts in defining the social security technical nexus. One of their advantages is to indicate organizational weaknesses that require coping with overload by the people exposed to it and, therefore, the work conditions that can cause negative effects on workers´ health.


To the Institute of National Social Security (Instituto Nacional do Seguro Social - INSS) of the Brazilian Ministry of Social Security, for the authorization to collect data; and to the Laboratory of Populational Studies (Laboratório de Estudos Populacionais - LEP) of the School of Public Health of the University of São Paulo, Brazil, for the technical support.


1. Nieuwenhuijsen K, Verbeek JH, de Boer AG, Blonk RW, van Dijk FJ. Predicting the duration of sickness absence for patients with common mental disorders in occupational health care. Scand J Work Environ Health 2006; 32(1): 67-74. [ Links ]

2. Silva Junior JS, Fischer FM. Disability due to mental illness: social security benefits in Brazil 2008-2011. Rev Saúde Pública 2014; 48(1): 186-90. [ Links ]

3. International Labour Office. Psychosocial factors at work: recognition and control. Report of the Joint ILO/WHO Committee on Occupational Health. Ninth Session. Geneva: International Labour Organization; 1984. [ Links ]

4. Karasek Junior RA. Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q 1979; 24(2): 285-307. [ Links ]

5. Theorell T, Perski A, Akerstedt T, Sigala F, Ahlberg-Hultén G, Svensson J, et al. Changes in job strain in relation to changes in psychological state: a longitudinal study. Scand J Work Environ Health1988; 14(3): 189-96. [ Links ]

6. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol 1996; 1(1): 27-41. [ Links ]

7. Head J, Kivimäki M, Siegrist J, Ferrie JE, Vahtera J, Shipley MJ, et al. Effort-reward imbalance and relational injustice at work predict sickness absence: the Whitehall II study. J Psychosom Res 2007; 63(4): 433-40. [ Links ]

8. Griep RH, Rotenberg L, Chor D, Toivanen S, Landsbergis P. Beyond simple approaches to studying the association between work characteristics and absenteeism: combining the DCS and ERI models. Work Stress 2010; 24(2): 179-95. [ Links ]

9. Janssens H, Clays E, De Clercq B, Casini A, De Bacquer D, Kittel F, et al. The relation between psychosocial risk factors and cause-specific long-term sickness absence. Eur J Public Health 2014; 24 (3): 428-33. [ Links ]

10. Ndjaboué R, Brisson C, Vézina M, Blanchette C, Bourbonnais R. Effort-reward imbalance and medically certified absence for mental health problems: a prospective study of white-collar workers. Occup Environ Med 2014; 71(1): 40-7. [ Links ]

11. Wang MJ, Mykletun A, Møyner EI, Øverland S, Henderson M, Stansfeld S, et al. Job strain, health and sickness absence: results from the Horland Health Study. PLoS One 2014; 22; 9(4): e96025. [ Links ]

12. Silva-Junior JS, Fischer FM. Long-term sickness absence due to mental disorders is associated with individual features and psychosocial work conditions. PLoS One 2014; 9(12): e115885. [ Links ]

13. Glina DMR, Rocha LE, Batista ML, Mendonça MGV. Saúde mental e trabalho: uma reflexão sobre o nexo com o trabalho e o diagnóstico, com base na prática [Mental health and work: a discussion of the connection between work and diagnosis based on daily practice]. Cad Saúde Pública 2001; 17(3): 607-16. [ Links ]

14. Brasil. Decreto nº 3.048, de 06 de maio de 1999. Aprova o Regulamento da Previdência Social, e dá outras providências. Brasília: Diário Oficial da União; 1999. [ Links ]

15. Brasil. Lei nº 8.213, de 24 de julho de 1991. Dispõe sobre os Planos de Benefícios da Previdência Social e dá outras providências. Brasília: Diário Oficial da União; 1991. [ Links ]

16. Brasil. Decreto nº 6.042, de 12 de fevereiro de 2007. Altera o Regulamento da Previdência Social, aprovado pelo Decreto no 3.048, de 6 de maio de 1999, disciplina a aplicação, acompanhamento e avaliação do Fator Acidentário de Prevenção - FAP e do Nexo Técnico Epidemiológico, e dá outras providências. Brasília:; Diário Oficial da União 2007. [ Links ]

17. Alves MGM, Chor D, Faerstein E, Lopes CS, Werneck GL. Short version of the "job stress scale": a Portuguese-language adaptation. Rev Saúde Pública 2004; 38(2): 164-71. [ Links ]

18. Chor D, Werneck GL, Faerstein E, Alves MGM, Rotenberg L. The Brazilian version of the effort-reward imbalance questionnaire to assess job stress. Cad Saúde Pública 2008; 24(1): 219-24. [ Links ]

19. Brasil. Decreto nº 8.036, de 11 de maio de 1990. Dispõe sobre o Fundo de Garantia do Tempo de Serviço, e dá outras providências. Brasília: Diário Oficial da União 1990. [ Links ]

20. Foss L, Gravseth HM, Kristensen P, Claussen B, Mehlum IS, Skyberg K. Risk factors for long-term absence due to psychiatric sickness: a register-based 5-year follow-up from the Oslo Health Study. J Occup Environ Med 2010; 52(7): 698-705. [ Links ]

21. Tsutsumi A, Kayaba K, Theorell T, Siegrist J. Association between job stress and depression among Japanese employees threatened by job loss in a comparison between two complementary job-stress models. Scand J Work Environ Health2001; 27(2): 146-53. [ Links ]

22. Silva Junior JS, Almeida FSS, Morrone LC. Discussão sobre o nexo técnico epidemiológico previdenciário [Discussion about use of Brazilian social security tool to characterize work-related disability]. Rev Bras Med Trab 2012; 10(2): 72-9. [ Links ]

23. Silva-Junior JS, Almeida FSS, Santiago MP, Morrone LC. Caracterização do nexo técnico epidemiológico pela perícia médica previdenciária nos benefícios auxílio-doença [Characterization of the technical epidemiological nexus in social security sickness benefits by medical experts]. Rev Bras Saúde Ocup 2014; 39(130): 239-46. [ Links ]

Financial support: none.

Received: December 10, 2014; Accepted: July 10, 2015

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