BRIEF REPORT
Predictors of Depression Among a Sample of South African Mortuary Workers Jani Nöthling, MA, Keith Ganasen, FCPsych, and Soraya Seedat, FCPsych, PhD Abstract: Mortuary workers are at high risk of developing depression and other psychiatric disorders owing to the nature of their work and exposure to deceased victims of violent deaths. Few studies have investigated mental health among mortuary workers in low- and middle-income countries. Participants (N = 45) were recruited from mortuaries in South Africa and completed a battery of questionnaires measuring depression, physical health, perceived stress, fear of blood/injury/mutilation, and resilience. Participants with self-reported depression and posttraumatic stress disorder (PTSD) comprised 13.3% and 4.4% of the sample, respectively. Inexperienced mortuary workers had a higher prevalence rate of depression (16.7%) compared with experienced workers (9.5%). Prevalence of PTSD did not differ significantly between inexperienced (4.2%) and experienced (4.8%) workers. Physical health, perceived stress, fear of blood/ injury/mutilation, and resilience were significant predictors of depression in the combined group (experienced and inexperienced). However, perceived stress was the only significant predictor of depression, in multiple regression, in the combined group. Inexperienced workers had significantly higher levels of blood/ injury/mutation fear and depression. Mortuary workers seem to be at increased risk of depression, especially inexperienced workers. Perceived poor health, lower levels of resilience, and blood/injury/mutilation fears may lead to increased perceived stress among mortuary workers, which may, in turn, lead to depression. Interventions focused on promoting mental health may be beneficial to all mortuary workers, and preparatory training related to mental health may be beneficial to inexperienced mortuary workers before occupational uptake. Key Words: Mortuary workers, depression, posttraumatic stress disorder, mental health, level of experience (J Nerv Ment Dis 2015;203: 226–230)
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epeated occupational exposure to death and dead bodies is a significant risk factor for the development of mental health problems (Alexander and Klein, 2001; Beaton et al., 1998; Bennett et al., 2004; Fullerton et al., 2004; Jonsson et al., 2003; Regehr et al., 2002; Schiraldi, 2009; Ward et al., 2006a, 2006b). Emergency care workers, for example, police officers, fire fighters, ambulance workers, military personnel, and disaster workers, are at increased risk of developing depression and other psychiatric disorders (Bennett et al., 2004; Fullerton et al., 2004). Mortuary workers are a high-risk group, too, owing to their daily exposure to corpses and repeated confrontation with death and bereavement. The prevalence of common mental disorders among mortuary workers and emergency workers who are exposed to the dead ranges from between 5.6% and 16.4% for depression to 5.9% and 22.5% for posttraumatic stress disorder (PTSD) (Bills et al., 2008; Fullerton et al., 2004). Globally, however, mortuary workers represent an understudied population. Mortuary workers are repeatedly exposed to human remains and periodically exposed to autopsies and embalming and the disturbing sights and smells that accompany these processes (Brysiewicz, 2007). In some instances, mortuary workers are exposed to severely mutilated
Department of Psychiatry, Stellenbosch University, Cape Town, South Africa. Send reprint requests to Jani Nöthling, MA, Department of Psychiatry, Faculty of Medicine and Health Sciences, PO Box 19063, Tygerberg, South Africa 7505. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20303–0226 DOI: 10.1097/NMD.0000000000000260
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remains due to unnatural death, such as infant death syndrome, death of children, homicide, suicide, drowning, burning, and motor and industrial accidents (Goldenhar et al., 2001). Frequent exposure to death due to unnatural causes is also associated with higher levels of concern about physical health (Kroshus et al., 1995). Concerns about physical health among mortuary workers may additionally be elevated due to the increased risk of exposure to blood-borne pathogens (e.g., tuberculosis, HIV, and hepatitis B and C, through blood splashes, cuts, and needle stick injuries) (Goldenhar et al., 2001; Ogunnowo et al., 2012). Increased exposure to blood and the consequences thereof may lead to fears of blood or injury related to mutilated body parts, which, in turn, increases the risk of developing depression (Bienvenu and Eaton, 1998; Deacon and Olatunji, 2007). Poor perceived health and the presence of somatic symptoms also contribute to the risk of emergent depression and the exacerbation of depression (Bao et al., 2003; Haug et al., 2004; Ohayon and Schatzberg, 2003). Other job-related stressors have been identified in this group. These stressors may be associated with feeling ostracized, stigmatized, and isolated from society (owing to the nature of the job), leading, in turn, to decreased social support and resilience (Goldenhar et al., 2001; McCarroll et al., 1993; Patwary, 2010; Thompson, 1991). Lower levels of resilience are a significant predictor of depression and poor mental health (Connor and Zhang, 2006; Davydov et al., 2010; Fredrickson et al., 2003; Fossion et al., 2013; Wingo et al., 2010). Perceived stress (i.e., perception of the stressor as personally significant) is particularly important. The physical work environment, isolation, harassment, and discrimination are significant predictors of perceived stress among mortuary workers, and perceived stress is, in turn, a significant predictor of depression (Goldenhar et al., 2001). Factors related to remains and the level of experience in handling remains may impact on distress levels in mortuary workers (McCarroll et al., 1995, 1996). The anticipated stress of handling remains has been associated with the gruesomeness of the condition of remains, the emotional link between the handler and remains, and personal threat related to the handling of remains (McCarroll et al., 1995). McCarroll et al. (1996) compared dentists who assisted in identifying remains of deceased burn victims with those who did not assist. The authors found that handling remains of children and severely burned remains were the most disturbing to work with. They also reported that dentists who handled remains had higher levels of intrusive, obsessive compulsive, and depressive symptoms (McCarroll et al., 1996). In addition to handling remains, the level of experience and preparedness are important. Inexperienced dentists (that is, first time handlers of remains) had significantly higher levels of stress related to the handling of remains compared with experienced dentists. A higher level of social support was associated with lower levels of obsessive compulsive, depressive, and anxious symptoms among inexperienced dentists who handled remains. In addition, lack of disaster preparedness training among workers and volunteers involved in rescue/recovery work may place them at a higher risk of developing PTSD (Bills et al., 2008; Perrin et al., 2007). To date, no quantitative studies have investigated the mental health of mortuary workers in a low- or middle-income country not related to war or disaster work. In a middle-income country like South Africa, mortuary workers may be at an even higher occupational risk
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
of developing metal illness, compared with their international counterparts, given the high violent crime rate in South Africa and the consequent higher exposure to deceased victims of violent deaths (Bradshaw et al., 2005; Seedat et al., 2009). The purpose of this study, firstly, was to investigate the relationship between perceived stress, physical health status, blood/injury/ mutilation fear, resilience, and depression in a sample of South African mortuary workers and, secondly, to determine the rate of depression and PTSD.
METHODS The study followed a cross-sectional design. The sample consisted of 45 mortuary workers, of which 26 were forensic officers, 13 were administrative staff, 4 were cleaners, and 2 were mortuary managers. All mortuary workers were exposed to the dead and had either seen or handled dead bodies. Data were collected in 2006 and 2007. Mortuary workers were recruited from three mortuaries in the Western Cape region in South Africa. The mortuary manager at each facility was approached by one of the researchers for approval to recruit at the relevant mortuary, after which written informed consent was obtained from all participants and assessments were completed. Mortuaries in South Africa are governed by the Department of Health and are situated on hospital premises. Employees are protected by the Basic Conditions of Employment Act (1997). According to this act, employers are responsible for creating a conducive work environment and favorable working conditions. The act focuses on promoting health, safety, and family responsibilities. Mortuary employees have access to the Employee, Health and Wellness Department, which offers counseling and skills to manage stress, trauma, and the negative impact of work environments. Ethics approval for this study was obtained from the Health Research Ethics Committee at Stellenbosch University, Cape Town, South Africa. Participants completed a demographic questionnaire and were assessed with a battery of questionnaires related to mental health, which included the following: (1) The Centre for Epidemiologic Studies– Depression Scale (CES-D) was used to screen for depression. The scale consists of 16 items measured on a 5-point Likert scale (Radloff, 1977). The CES-D has good reliability, with Cronbach's alpha scores ranging between 0.85 and 0.90 for general populations and a South African population (Pretorius, 1991; Radloff, 1977). (2) The Davidson Trauma Scale (DTS) was used to screen for PTSD. The scale assesses the frequency and severity of PTSD symptoms on a 5-point Likert scale and consists of 17 items (Davidson et al., 1997). The DTS has shown good test-retest reliability (r = 0.86), internal consistency (r = 0.99), and validity (Davidson et al., 1997). (3) The Patient Health Questionnaire (PHQ-15) was used to measure participants' perception of their physical health and somatic symptoms (Kroenke et al., 2002). The PHQ has shown good reliability, with a Cronbach's alpha score of 0.80 (Kroenke et al., 2002). (4) The 10-item Perceived Stress Scale (PSS-10), measured on a 4-point Likert scale, was used to measure participants' perception of personal stress. The scale consists of 15 items measured on a 3-point Likert scale (Cohen et al., 1983). The PSS has shown good reliability and factorial and construct validity (Cohen and Williamson, 1998). (5) The Mutilation Questionnaire (MQ) was used to assess fear of blood or injury related to mutilated body parts. The scale consists of 30 items and responses were dichotomous (Kleinknecht and Thorndike, 1990). The MQ has shown good internal consistency (Klorman et al., 1974). (6) The Connor-Davidson Resilience Scale (CD-RISC) was used to measure resilience. The scale consists of 25 items measured on a 5-point Likert scale (Connor and Davidson, 2003). The CD-RISC has shown good reliability and validity (Connor and Davidson, 2003). Data were analyzed using SPSS version 20. Descriptive statistics were computed. Four simple linear regression models were computed to determine the individual predictive power of the variables physical
Depression Among Mortuary Workers
health, perceived stress, fear of blood, injury, or mutilation, and resilience, on the outcome variable depression. A multiple regression model was computed to determine the combined predictive power of the variables physical health, perceived stress, fear of blood/injury/mutilation, and resilience on the outcome variable depression. We intended to repeat the analysis with PTSD as the outcome variable, but this was not possible owing to a) few participants who completed the DTS (as most did not endorse an index trauma); b) the markedly skewed distribution of PTSD scores, and c) the unequal group size for those with PTSD versus those without.
RESULTS Sample Demographics and Prevalence of Depression and PTSD Most participants were men (57.8%). The mean age of participants was 32 years (range, 20–46 years). Participants were mainly of colored (mixed) descent (44.4%), and most were married at the time of assessment (53.3%). Participants had varied levels of work experience. Most (n = 24) were newly recruited mortuary workers with no previous experience. The remainder (n = 21) had an average of 5 years of work experience (range 6 months to 18 years). The prevalence of self-reported depression was high, with 13.3% scoring above cutoff on the CES-D. The prevalence of depression was higher among inexperienced workers (16.7%; n = 4) compared with experienced workers (9.5%; n = 2). Results are presented in Table 1. Twenty-one mortuary workers (47%) endorsed discrete traumatogenic events (namely, sudden unexpected death of someone close to them, physical assault with a weapon, transport accident, serious accident at home or work, witnessing a fire or explosion, exposure to violent death, child physical abuse, and domestic violence). Of these, only two (4.4%) met criteria for PTSD as assessed on the DTS (Davidson et al., 1997). There was no evident difference in PTSD prevalence between inexperienced workers (4.2%; n = 1) and experienced workers (4.8%; n = 1), and none of the aforementioned traumatic events were significantly associated with depression or PTSD. TABLE 1. Descriptive Statistics for Depression Status, PTSD Status, and Demographic Variables n Depression status (CES-D) Above cutoff Below cutoff PTSD status (DTS) Above cutoff Below cutoff Sex Female Male Age, yrs Population group Black Colored White Marital status Single Married/living with a partner Divorced/separated
45 6 39 21a 2 19 45 19 26 45 44a 12 20 12 44a 15 24 5
%
Mean
13.3 86.7 4.4 42.2 57.8 42.2 32 27.3 45.5 27.3 33.3 53.3 11.1
a
Missing data.
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Differences in Level of Experience, Occupation, Age, and Sex There were no significant differences between newly appointed mortuary workers and experienced mortuary workers on resilience scores (U = 140.5, p = 0.73), perceived stress scores (U = 211, p = 0.899), self-reported physical health (U = 158, p = 0.083), and PTSD scores (U = 136, p = 0.177). Inexperienced mortuary workers had significantly higher levels of blood/injury/mutilation fears (U = 154.5, p = 0.47) and depression (U = 147.5, p = 0.032) compared with experienced mortuary workers. There were no significant differences between forensic officers and other mortuary staff (cleaners, managers, and administrative staff ) with regard to blood/injury/mutilation fears (U = 207, p = 0.353), resilience (U = 161.5, p = 0.227), depression (U = 247, p = 1.00), perceived stress (U = 208, p = 0.675), and PTSD (U = 183, p = 0.817) scores. Forensic officers scored significantly lower on the PHQ compared with other mortuary staff (U = 153, p = 0.050), suggesting that the latter group had significantly more somatic symptoms. There were no significant associations between age and blood/injury/mutilation fears, resilience, depression, perceived stress, physical health, and PTSD. Female mortuary workers endorsed significantly more somatic symptoms compared with male mortuary workers (U = 124, p = 0.006). There were no significant sex differences in blood/injury/mutilation fears (U = 164, p = 0.54), depression (U = 185.5, p = 0.156), perceived stress (U = 155, p = 0.084), PTSD (U = 142, p = 0.149), and resilience (U = 202.5, p = 0.797) scores.
TABLE 3. Model Summary Predicting Depression Model 1 2 3 4 5
R2
ΔR2
F
df1
df2
p
0.220 0.291 0.132 0.096 0.461
0.202 0.273 0.112 0.074 0.398
11.860 16.804 6.534 4.256 7.270
1 1 1 1 4
42 41 43 40 34
0.001* 0.000** 0.014* 0.046* 0.000**
1. Predictor: physical health (PHQ); outcome: depression (CES-D). 2. Predictor: perceived stress (PSS); outcome: depression (CES-D). 3. Predictor: blood/ injury/mutilation (MQ); outcome: depression (CES-D). 4. Predictor: resilience; outcome: depression (CES-D). 5. Predictor: physical health (PHQ), perceived stress (PSS), blood/injury/mutilation (MQ), resilience (CD-RISC); outcome: depression (CES-D). *p < 0.05. **p < 0.01.
explained 7.4% (F1, 40 = 4.26, p = 0.046) of the variance. Physical health (B = 0.44, t38 = 1.98, p = 0.056), fear of blood/injury/mutilation (B = 0.17, t38 = 0.68, p = 0.503), and resilience (B = −0.12, t38 = −1.67, p = 0.105) failed to predict depression when these variables were added together in the multiple regression model, model 5, with perceived stress. Perceived stress (B = 0.58, t38 = −2.58, p = 0.014) was the only significant predictor of depression in the multiple regression model. Model 5 significantly explained 39.8% (F4, 34 = 7.27, p = 0.000) of the variance in depression.
Predictors of Depression The parameters for the variables predicting depression and the model summary statistics are presented in Tables 2 and 3, respectively. Physical health (B = 0.71, t43 = 3.44, p = 0.001) was a significant predictor of depression in model 1 and explained 20.2% (F1, 42 = 11.86, p = 0.001) of the variance. Perceived stress (B = −0.80, t42 = 4.10, p < 0.000) was a significant predictor of depression in model 2 and explained 27.3% (F1, 41 = 16.8, p < 0.000) of the variance. Fear of blood/ injury/mutilation (B = 0.66, t44 = 2.56, p = 0.014) was a significant predictor of depression in model 3 and explained 11.2% (F1, 43 = 6.53, p = 0.014) of the variance. Resilience (B = −0.17, t41 = −2.06, p = 0.046) was a significant predictor of depression in model 4 and
DISCUSSION We found a rate of 13.3% of self-reported depression and 4.4% for PTSD in this sample of mortuary workers. The 12-month prevalence of depression and PTSD in the general South African population is estimated at 4.9% and 0.6%, respectively. Mortuary workers seem to be at an increased risk of developing depression and PTSD compared with the general population, especially the inexperienced mortuary worker group with a prevalence rate of 16.7% for depression (Herman et al., 2009). The rate of depression in inexperienced workers falls slightly above the range of prevalence rates for depression (5.6%– 16.4%) found in previous studies of participants exposed to the dead
TABLE 2. Parameters for the Variables Predicting Depression Unstandardized Model 1
Depression (constant) Physical health (PHQ) Depression (constant) Perceived stress (PSS) Depression (constant) Blood/injury/mutilation (MQ) Depression (constant) Resilience (CD-RISC) Depression (constant) Physical health (PHQ) Perceived stress (PSS) Blood/injury/mutilation (MQ) Resilience (CD-RISC)
2 3 4 5
n
B
SE
43
5.33 0.71 −1.62 0.80 3.04 0.66 22.33 −0.17 7.40 0.44 0.58 0.17 −0.12
1.56 0.21 2.79 0.19 2.50 0.26 6.77 0.08 6.89 0.22 0.23 0.25 0.07
42 44 41 38
Standardized Beta Coefficients 0.47 0.54 0.36 −0.31 0.28 0.38 0.10 −0.22
t
P
3.41 3.44 −0.58 4.10 1.22 2.56 3.30 −2.06 1.07 1.98 2.58 0.68 −1.67
0.001 0.001* 0.566 0.000* 0.231 0.014* 0.002 0.046* 0.291 0.056 0.014* 0.503 0.105
Models 1–5: Outcome: depression (CES-D). *p < 0.05.
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(Bills et al., 2008; Fullerton et al., 2004). The prevalence of depression reported in the experienced group and the rate for the combined group falls within the previously reported rates. However, the rate for PTSD falls below the range (5.9%–22.5%) found in previous studies (Bills et al., 2008; Fullerton et al., 2004). The aforementioned studies included mortuary workers involved in war and disaster work, and the overwhelming, unpredictable, and gruesome nature of this type of work may have contributed to higher levels of PTSD. Our primary aim was to investigate the relationship between physical health, perceived stress, blood/injury/mutilation fear, resilience, and depression. First, physical health, perceived stress, blood/ injury/mutilation fear, and resilience were all significant predictors of depression in simple regression analyses. Our findings correspond with previous findings: recurrent exposure to traumatic stressors, such as death and the deceased can increase the likelihood of somatic symptoms (McCarroll et al., 2002). Mortuary workers are also more likely to worry about common, minor symptoms that are usually dismissed, which can lead to increased awareness of physical health status (McCarroll et al., 2002). We also found that female mortuary workers reported higher levels of somatic symptoms compared with men, and that forensic officers reported lower levels of somatic symptoms compared with other mortuary staff (e.g., administrative staff, cleaners). Greater somatization among women is consistent with findings from other epidemiologic and clinic-based studies (Barsky et al., 2001; Hiller et al., 2006; Matud, 2004; Nimnuan et al., 2001). Surprisingly, higher rates of somatization among women did not correspond with higher rates of depression and PTSD in the current study. The latter finding may, in part, be accounted for by the small sample size. Forensic officers reported lower levels of somatic symptoms compared with other mortuary staff. It may be hypothesized that the former group is less prone to somatization because of greater exposure to dead bodies, whereas the latter group is more prone to somatization on account of less exposure to dead bodies and a lack of proper training in dealing with this exposure, although this requires further investigation. Second, perceived stress has been identified as a predictor of higher levels of depression and anxiety among mortuary workers (Goldenhar et al., 2001). South African mortuary workers face unique challenges because of an overburdened health care system and a high burden of violence and injury-related deaths (Bradshaw et al., 2005). Often, mortuary workers have to inform the family of the deceased and provide basic counseling, for which they may lack professional skills (Brysiewicz, 2007; Ward et al., 2006a, 2006b). Their work environment and job demands may be perceived as highly stressful, with chronic situational exposure to stress associated with depression (Goldenhar et al., 2001; Ward et al., 2006a, 2006b). Third, fear of blood, bodily injury, and mutilation is a common phobia in general population studies and is associated with an increased risk for psychiatric disorders (Bienvenu and Eaton, 1998). Fear of blood/injury/mutilation is also related to physical health, owing to an increased risk of exposure to blood-borne pathogens in mortuaries (Goldenhar et al., 2001; Ogunnowo et al., 2012). Inexperienced mortuary workers had more blood/injury/mutilation fears and depression compared with experienced mortuary workers. Inexperienced health workers are more vulnerable to injuries and, therefore, exposure to contaminated blood (Kumakech et al., 2011; Reis et al., 2004; Shariati et al., 2007). Inexperienced mortuary workers may have greater blood/injury/ mutilation fear because of their increased vulnerability. The added anxiety related to starting a new job may have contributed to higher levels of depression in this group (Harris, 2001). Fourth, resilience is arguably a strong preventive factor against the development of depression. Individuals working in stressful environments with low levels of resilience may be at greater risk of developing mental illness (Edward, 2005). Social support, an important protective factor against the development of mental illness, is often compromised among mortuary workers. Death and mortality are topics that tend to
Depression Among Mortuary Workers
be avoided, and working with the deceased may lead to social ostracism, discrimination, and harassment, which may diminish job satisfaction, self-esteem, and self-worth, leaving an individual vulnerable to mental illness (Goldenhar et al., 2001; Patwary, 2010). In the current study, perceived stress was the only significant predictor of depression in multiple regression analysis. It is possible that perceived poor health, less resilience, and blood/injury/mutilation fears lead to a greater inability to cope with daily demands, higher levels of perceived stress, and depression (Goldenhar et al., 2001). Constant confrontation with human death and mortality may further increase the risk for depression (Patwary, 2010). Longitudinal tracking of the course of mental and physical health in mortuary workers will enhance our understanding of the causal contribution of perceived stress, blood/injury/ mutilation fears, physical health, and resilience to depression outcomes. ACKNOWLEDGMENTS The authors acknowledge and thank Celine Fjeldheim, Karin Pretorius, Marina Basson, and Karen Cloete for their contribution to this study. This work was supported by the South African Research Chairs Initiative in Posttraumatic Stress Disorder (Department of Science and Technology and the National Research Foundation) and the Medical Research Council on Anxiety and Stress Disorders. DISCLOSURES The authors declare no conflict of interest. REFERENCES Alexander DA, Klein S (2001) Ambulance personnel and critical incidents: Impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry. 178:76–81. Barsky AB, Peekna HM, Borus JF (2001) Somatic symptom reporting in women and men. J Gen Intern Med. 16:266–275. Basic Conditions of Employment Act (1997) (DOL) 23.1 (RSA). Bao Y, Sturm R, Croghan TW (2003) A national study of the effect of chronic pain on the use of health care by depressed persons. Psychiatr Serv. 54:693–697. Beaton R, Murphy S, Johnson C, Pike K, Corneil W (1998) Exposure to duty-related incident stressors in urban fire fighters and paramedics. J Trauma Stress. 11:821–828. Bennett P, Williams Y, Page N, Hood K, Woollard M (2004) Levels of mental health problems among UK emergency ambulance workers. Emerg Med J. 21:235–236. Bienvenu OJ, Eaton WW (1998) The epidemiology of blood-injury phobia. Psychol Med. 28:1129–1136. Bills CB, Levy NAS, Sharma V, Charney DS, Herbert R, Moline J, Katz CL (2008) Mental health of workers and volunteers responding to events of 9/11: Review of the literature. Mt Sinai J Med. 75:115–127. Bradshaw D, Nanna N, Groenewald P, Joubert J, Laubscher R, Nojilana B, Norman R, Pieterse D, Schneider M (2005) Provincial mortality in South Africa, 2000—Priority setting for now and a benchmark for the future. S Afr Med J. 95:496–503. Brysiewicz P (2007) The lived experience of working in a mortuary. Acc Emerg Nurs. 15:88–93. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav. 24:385–396. Cohen S, Williamson G (1988) Perceived stress in a probability sample of the United States. In Spacapan S, Oskamp S (Eds), The social psychology of health: Claremont symposium on applied psychology (pp 31–66). Newbury Park, CA: Sage. Connor KM, Davidson JR (2003) Development of a new resilience scale: The ConnorDavidson Resilience Scale. Depress Anxiety. 18:76–82.
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Jonsson A, Segesten K, Mattsson B (2003) Post-traumatic stress among Swedish ambulance personnel. Emerg Med J. 20:79–84. Kleinknecht RA, Thorndike RM (1990) The Mutilation Questionnaire as a predictor of blood/injury fear and fainting. Behav Res Ther. 28:429–437. Klorman R, Hastings J, Weerts T, Melamed B, Lang P (1974) Psychometric description of some specific-fear questionnaires. Behav Ther. 5:401–409. Kroenke K, Spitzer RL, Williams JB (2002) The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 64:258–266. Kroshus J, Swarthout D, Tibbetts S (1995) Critical incident stress among funeral directors: Identifying factors relevant for mental health counseling. J Ment Health Couns. 17:441–450. Kumakech E, Achora S, Berggren V, Bajunirwe F (2011) Occupational exposure to HIV: A conflict situation for health workers. Int Nurs Rev. 58:454–462. Matud P (2004) Gender differences in stress and coping styles. Pers Individ Differ. 37:1401–1415.
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Seedat M, van Niekerk A, Jewkes R, Suffla S, Ratele K (2009) Violence and injuries in South Africa: Prioritising an agenda for prevention. Lancet. 374:1011–1022. Shariati B, Shahidzadeh-Mahani Ali, Oveysi T, Akhlaghi H (2007) Accidental exposure to blood in medical interns of Tehran University of Medical Sciences. J Occup Health. 49:317–321. Thompson WE (1991) Handling the stigma of handling the dead: Morticians and funeral directors. Deviant Behav. 12:403–429. Ward CL, Flisher AJ, Kepe L (2006a) A pilot study of an intervention to prevent negative mental health consequences of forensic mortuary work. J Trauma Stress. 19:159–163. Ward CL, Lombard CJ, Gwebushe N (2006b) Critical incident exposure in South African emergency services personnel: Prevalence and associated mental health issues. Emerg Med J. 23:226–231. Wingo AP, Wrenn G, Pelletier T, Gutman AR, Bradley B, Ressler KJ (2010) Moderating effects of resilience on depression in individuals with a history of childhood abuse or trauma exposure. J Affect Disord. 126:411–414.
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Predictors of Depression Among a Sample of South African Mortuary Workers Jani Nöthling, MA, Keith Ganasen, FCPsych, and Soraya Seedat, FCPsych, PhD Abstract: Mortuary workers are at high risk of developing depression and other psychiatric disorders owing to the nature of their work and exposure to deceased victims of violent deaths. Few studies have investigated mental health among mortuary workers in low- and middle-income countries. Participants (N = 45) were recruited from mortuaries in South Africa and completed a battery of questionnaires measuring depression, physical health, perceived stress, fear of blood/injury/mutilation, and resilience. Participants with self-reported depression and posttraumatic stress disorder (PTSD) comprised 13.3% and 4.4% of the sample, respectively. Inexperienced mortuary workers had a higher prevalence rate of depression (16.7%) compared with experienced workers (9.5%). Prevalence of PTSD did not differ significantly between inexperienced (4.2%) and experienced (4.8%) workers. Physical health, perceived stress, fear of blood/ injury/mutilation, and resilience were significant predictors of depression in the combined group (experienced and inexperienced). However, perceived stress was the only significant predictor of depression, in multiple regression, in the combined group. Inexperienced workers had significantly higher levels of blood/ injury/mutation fear and depression. Mortuary workers seem to be at increased risk of depression, especially inexperienced workers. Perceived poor health, lower levels of resilience, and blood/injury/mutilation fears may lead to increased perceived stress among mortuary workers, which may, in turn, lead to depression. Interventions focused on promoting mental health may be beneficial to all mortuary workers, and preparatory training related to mental health may be beneficial to inexperienced mortuary workers before occupational uptake. Key Words: Mortuary workers, depression, posttraumatic stress disorder, mental health, level of experience (J Nerv Ment Dis 2015;203: 226–230)
R
epeated occupational exposure to death and dead bodies is a significant risk factor for the development of mental health problems (Alexander and Klein, 2001; Beaton et al., 1998; Bennett et al., 2004; Fullerton et al., 2004; Jonsson et al., 2003; Regehr et al., 2002; Schiraldi, 2009; Ward et al., 2006a, 2006b). Emergency care workers, for example, police officers, fire fighters, ambulance workers, military personnel, and disaster workers, are at increased risk of developing depression and other psychiatric disorders (Bennett et al., 2004; Fullerton et al., 2004). Mortuary workers are a high-risk group, too, owing to their daily exposure to corpses and repeated confrontation with death and bereavement. The prevalence of common mental disorders among mortuary workers and emergency workers who are exposed to the dead ranges from between 5.6% and 16.4% for depression to 5.9% and 22.5% for posttraumatic stress disorder (PTSD) (Bills et al., 2008; Fullerton et al., 2004). Globally, however, mortuary workers represent an understudied population. Mortuary workers are repeatedly exposed to human remains and periodically exposed to autopsies and embalming and the disturbing sights and smells that accompany these processes (Brysiewicz, 2007). In some instances, mortuary workers are exposed to severely mutilated
Department of Psychiatry, Stellenbosch University, Cape Town, South Africa. Send reprint requests to Jani Nöthling, MA, Department of Psychiatry, Faculty of Medicine and Health Sciences, PO Box 19063, Tygerberg, South Africa 7505. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20303–0226 DOI: 10.1097/NMD.0000000000000260
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remains due to unnatural death, such as infant death syndrome, death of children, homicide, suicide, drowning, burning, and motor and industrial accidents (Goldenhar et al., 2001). Frequent exposure to death due to unnatural causes is also associated with higher levels of concern about physical health (Kroshus et al., 1995). Concerns about physical health among mortuary workers may additionally be elevated due to the increased risk of exposure to blood-borne pathogens (e.g., tuberculosis, HIV, and hepatitis B and C, through blood splashes, cuts, and needle stick injuries) (Goldenhar et al., 2001; Ogunnowo et al., 2012). Increased exposure to blood and the consequences thereof may lead to fears of blood or injury related to mutilated body parts, which, in turn, increases the risk of developing depression (Bienvenu and Eaton, 1998; Deacon and Olatunji, 2007). Poor perceived health and the presence of somatic symptoms also contribute to the risk of emergent depression and the exacerbation of depression (Bao et al., 2003; Haug et al., 2004; Ohayon and Schatzberg, 2003). Other job-related stressors have been identified in this group. These stressors may be associated with feeling ostracized, stigmatized, and isolated from society (owing to the nature of the job), leading, in turn, to decreased social support and resilience (Goldenhar et al., 2001; McCarroll et al., 1993; Patwary, 2010; Thompson, 1991). Lower levels of resilience are a significant predictor of depression and poor mental health (Connor and Zhang, 2006; Davydov et al., 2010; Fredrickson et al., 2003; Fossion et al., 2013; Wingo et al., 2010). Perceived stress (i.e., perception of the stressor as personally significant) is particularly important. The physical work environment, isolation, harassment, and discrimination are significant predictors of perceived stress among mortuary workers, and perceived stress is, in turn, a significant predictor of depression (Goldenhar et al., 2001). Factors related to remains and the level of experience in handling remains may impact on distress levels in mortuary workers (McCarroll et al., 1995, 1996). The anticipated stress of handling remains has been associated with the gruesomeness of the condition of remains, the emotional link between the handler and remains, and personal threat related to the handling of remains (McCarroll et al., 1995). McCarroll et al. (1996) compared dentists who assisted in identifying remains of deceased burn victims with those who did not assist. The authors found that handling remains of children and severely burned remains were the most disturbing to work with. They also reported that dentists who handled remains had higher levels of intrusive, obsessive compulsive, and depressive symptoms (McCarroll et al., 1996). In addition to handling remains, the level of experience and preparedness are important. Inexperienced dentists (that is, first time handlers of remains) had significantly higher levels of stress related to the handling of remains compared with experienced dentists. A higher level of social support was associated with lower levels of obsessive compulsive, depressive, and anxious symptoms among inexperienced dentists who handled remains. In addition, lack of disaster preparedness training among workers and volunteers involved in rescue/recovery work may place them at a higher risk of developing PTSD (Bills et al., 2008; Perrin et al., 2007). To date, no quantitative studies have investigated the mental health of mortuary workers in a low- or middle-income country not related to war or disaster work. In a middle-income country like South Africa, mortuary workers may be at an even higher occupational risk
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
of developing metal illness, compared with their international counterparts, given the high violent crime rate in South Africa and the consequent higher exposure to deceased victims of violent deaths (Bradshaw et al., 2005; Seedat et al., 2009). The purpose of this study, firstly, was to investigate the relationship between perceived stress, physical health status, blood/injury/ mutilation fear, resilience, and depression in a sample of South African mortuary workers and, secondly, to determine the rate of depression and PTSD.
METHODS The study followed a cross-sectional design. The sample consisted of 45 mortuary workers, of which 26 were forensic officers, 13 were administrative staff, 4 were cleaners, and 2 were mortuary managers. All mortuary workers were exposed to the dead and had either seen or handled dead bodies. Data were collected in 2006 and 2007. Mortuary workers were recruited from three mortuaries in the Western Cape region in South Africa. The mortuary manager at each facility was approached by one of the researchers for approval to recruit at the relevant mortuary, after which written informed consent was obtained from all participants and assessments were completed. Mortuaries in South Africa are governed by the Department of Health and are situated on hospital premises. Employees are protected by the Basic Conditions of Employment Act (1997). According to this act, employers are responsible for creating a conducive work environment and favorable working conditions. The act focuses on promoting health, safety, and family responsibilities. Mortuary employees have access to the Employee, Health and Wellness Department, which offers counseling and skills to manage stress, trauma, and the negative impact of work environments. Ethics approval for this study was obtained from the Health Research Ethics Committee at Stellenbosch University, Cape Town, South Africa. Participants completed a demographic questionnaire and were assessed with a battery of questionnaires related to mental health, which included the following: (1) The Centre for Epidemiologic Studies– Depression Scale (CES-D) was used to screen for depression. The scale consists of 16 items measured on a 5-point Likert scale (Radloff, 1977). The CES-D has good reliability, with Cronbach's alpha scores ranging between 0.85 and 0.90 for general populations and a South African population (Pretorius, 1991; Radloff, 1977). (2) The Davidson Trauma Scale (DTS) was used to screen for PTSD. The scale assesses the frequency and severity of PTSD symptoms on a 5-point Likert scale and consists of 17 items (Davidson et al., 1997). The DTS has shown good test-retest reliability (r = 0.86), internal consistency (r = 0.99), and validity (Davidson et al., 1997). (3) The Patient Health Questionnaire (PHQ-15) was used to measure participants' perception of their physical health and somatic symptoms (Kroenke et al., 2002). The PHQ has shown good reliability, with a Cronbach's alpha score of 0.80 (Kroenke et al., 2002). (4) The 10-item Perceived Stress Scale (PSS-10), measured on a 4-point Likert scale, was used to measure participants' perception of personal stress. The scale consists of 15 items measured on a 3-point Likert scale (Cohen et al., 1983). The PSS has shown good reliability and factorial and construct validity (Cohen and Williamson, 1998). (5) The Mutilation Questionnaire (MQ) was used to assess fear of blood or injury related to mutilated body parts. The scale consists of 30 items and responses were dichotomous (Kleinknecht and Thorndike, 1990). The MQ has shown good internal consistency (Klorman et al., 1974). (6) The Connor-Davidson Resilience Scale (CD-RISC) was used to measure resilience. The scale consists of 25 items measured on a 5-point Likert scale (Connor and Davidson, 2003). The CD-RISC has shown good reliability and validity (Connor and Davidson, 2003). Data were analyzed using SPSS version 20. Descriptive statistics were computed. Four simple linear regression models were computed to determine the individual predictive power of the variables physical
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health, perceived stress, fear of blood, injury, or mutilation, and resilience, on the outcome variable depression. A multiple regression model was computed to determine the combined predictive power of the variables physical health, perceived stress, fear of blood/injury/mutilation, and resilience on the outcome variable depression. We intended to repeat the analysis with PTSD as the outcome variable, but this was not possible owing to a) few participants who completed the DTS (as most did not endorse an index trauma); b) the markedly skewed distribution of PTSD scores, and c) the unequal group size for those with PTSD versus those without.
RESULTS Sample Demographics and Prevalence of Depression and PTSD Most participants were men (57.8%). The mean age of participants was 32 years (range, 20–46 years). Participants were mainly of colored (mixed) descent (44.4%), and most were married at the time of assessment (53.3%). Participants had varied levels of work experience. Most (n = 24) were newly recruited mortuary workers with no previous experience. The remainder (n = 21) had an average of 5 years of work experience (range 6 months to 18 years). The prevalence of self-reported depression was high, with 13.3% scoring above cutoff on the CES-D. The prevalence of depression was higher among inexperienced workers (16.7%; n = 4) compared with experienced workers (9.5%; n = 2). Results are presented in Table 1. Twenty-one mortuary workers (47%) endorsed discrete traumatogenic events (namely, sudden unexpected death of someone close to them, physical assault with a weapon, transport accident, serious accident at home or work, witnessing a fire or explosion, exposure to violent death, child physical abuse, and domestic violence). Of these, only two (4.4%) met criteria for PTSD as assessed on the DTS (Davidson et al., 1997). There was no evident difference in PTSD prevalence between inexperienced workers (4.2%; n = 1) and experienced workers (4.8%; n = 1), and none of the aforementioned traumatic events were significantly associated with depression or PTSD. TABLE 1. Descriptive Statistics for Depression Status, PTSD Status, and Demographic Variables n Depression status (CES-D) Above cutoff Below cutoff PTSD status (DTS) Above cutoff Below cutoff Sex Female Male Age, yrs Population group Black Colored White Marital status Single Married/living with a partner Divorced/separated
45 6 39 21a 2 19 45 19 26 45 44a 12 20 12 44a 15 24 5
%
Mean
13.3 86.7 4.4 42.2 57.8 42.2 32 27.3 45.5 27.3 33.3 53.3 11.1
a
Missing data.
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Differences in Level of Experience, Occupation, Age, and Sex There were no significant differences between newly appointed mortuary workers and experienced mortuary workers on resilience scores (U = 140.5, p = 0.73), perceived stress scores (U = 211, p = 0.899), self-reported physical health (U = 158, p = 0.083), and PTSD scores (U = 136, p = 0.177). Inexperienced mortuary workers had significantly higher levels of blood/injury/mutilation fears (U = 154.5, p = 0.47) and depression (U = 147.5, p = 0.032) compared with experienced mortuary workers. There were no significant differences between forensic officers and other mortuary staff (cleaners, managers, and administrative staff ) with regard to blood/injury/mutilation fears (U = 207, p = 0.353), resilience (U = 161.5, p = 0.227), depression (U = 247, p = 1.00), perceived stress (U = 208, p = 0.675), and PTSD (U = 183, p = 0.817) scores. Forensic officers scored significantly lower on the PHQ compared with other mortuary staff (U = 153, p = 0.050), suggesting that the latter group had significantly more somatic symptoms. There were no significant associations between age and blood/injury/mutilation fears, resilience, depression, perceived stress, physical health, and PTSD. Female mortuary workers endorsed significantly more somatic symptoms compared with male mortuary workers (U = 124, p = 0.006). There were no significant sex differences in blood/injury/mutilation fears (U = 164, p = 0.54), depression (U = 185.5, p = 0.156), perceived stress (U = 155, p = 0.084), PTSD (U = 142, p = 0.149), and resilience (U = 202.5, p = 0.797) scores.
TABLE 3. Model Summary Predicting Depression Model 1 2 3 4 5
R2
ΔR2
F
df1
df2
p
0.220 0.291 0.132 0.096 0.461
0.202 0.273 0.112 0.074 0.398
11.860 16.804 6.534 4.256 7.270
1 1 1 1 4
42 41 43 40 34
0.001* 0.000** 0.014* 0.046* 0.000**
1. Predictor: physical health (PHQ); outcome: depression (CES-D). 2. Predictor: perceived stress (PSS); outcome: depression (CES-D). 3. Predictor: blood/ injury/mutilation (MQ); outcome: depression (CES-D). 4. Predictor: resilience; outcome: depression (CES-D). 5. Predictor: physical health (PHQ), perceived stress (PSS), blood/injury/mutilation (MQ), resilience (CD-RISC); outcome: depression (CES-D). *p < 0.05. **p < 0.01.
explained 7.4% (F1, 40 = 4.26, p = 0.046) of the variance. Physical health (B = 0.44, t38 = 1.98, p = 0.056), fear of blood/injury/mutilation (B = 0.17, t38 = 0.68, p = 0.503), and resilience (B = −0.12, t38 = −1.67, p = 0.105) failed to predict depression when these variables were added together in the multiple regression model, model 5, with perceived stress. Perceived stress (B = 0.58, t38 = −2.58, p = 0.014) was the only significant predictor of depression in the multiple regression model. Model 5 significantly explained 39.8% (F4, 34 = 7.27, p = 0.000) of the variance in depression.
Predictors of Depression The parameters for the variables predicting depression and the model summary statistics are presented in Tables 2 and 3, respectively. Physical health (B = 0.71, t43 = 3.44, p = 0.001) was a significant predictor of depression in model 1 and explained 20.2% (F1, 42 = 11.86, p = 0.001) of the variance. Perceived stress (B = −0.80, t42 = 4.10, p < 0.000) was a significant predictor of depression in model 2 and explained 27.3% (F1, 41 = 16.8, p < 0.000) of the variance. Fear of blood/ injury/mutilation (B = 0.66, t44 = 2.56, p = 0.014) was a significant predictor of depression in model 3 and explained 11.2% (F1, 43 = 6.53, p = 0.014) of the variance. Resilience (B = −0.17, t41 = −2.06, p = 0.046) was a significant predictor of depression in model 4 and
DISCUSSION We found a rate of 13.3% of self-reported depression and 4.4% for PTSD in this sample of mortuary workers. The 12-month prevalence of depression and PTSD in the general South African population is estimated at 4.9% and 0.6%, respectively. Mortuary workers seem to be at an increased risk of developing depression and PTSD compared with the general population, especially the inexperienced mortuary worker group with a prevalence rate of 16.7% for depression (Herman et al., 2009). The rate of depression in inexperienced workers falls slightly above the range of prevalence rates for depression (5.6%– 16.4%) found in previous studies of participants exposed to the dead
TABLE 2. Parameters for the Variables Predicting Depression Unstandardized Model 1
Depression (constant) Physical health (PHQ) Depression (constant) Perceived stress (PSS) Depression (constant) Blood/injury/mutilation (MQ) Depression (constant) Resilience (CD-RISC) Depression (constant) Physical health (PHQ) Perceived stress (PSS) Blood/injury/mutilation (MQ) Resilience (CD-RISC)
2 3 4 5
n
B
SE
43
5.33 0.71 −1.62 0.80 3.04 0.66 22.33 −0.17 7.40 0.44 0.58 0.17 −0.12
1.56 0.21 2.79 0.19 2.50 0.26 6.77 0.08 6.89 0.22 0.23 0.25 0.07
42 44 41 38
Standardized Beta Coefficients 0.47 0.54 0.36 −0.31 0.28 0.38 0.10 −0.22
t
P
3.41 3.44 −0.58 4.10 1.22 2.56 3.30 −2.06 1.07 1.98 2.58 0.68 −1.67
0.001 0.001* 0.566 0.000* 0.231 0.014* 0.002 0.046* 0.291 0.056 0.014* 0.503 0.105
Models 1–5: Outcome: depression (CES-D). *p < 0.05.
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The Journal of Nervous and Mental Disease • Volume 203, Number 3, March 2015
(Bills et al., 2008; Fullerton et al., 2004). The prevalence of depression reported in the experienced group and the rate for the combined group falls within the previously reported rates. However, the rate for PTSD falls below the range (5.9%–22.5%) found in previous studies (Bills et al., 2008; Fullerton et al., 2004). The aforementioned studies included mortuary workers involved in war and disaster work, and the overwhelming, unpredictable, and gruesome nature of this type of work may have contributed to higher levels of PTSD. Our primary aim was to investigate the relationship between physical health, perceived stress, blood/injury/mutilation fear, resilience, and depression. First, physical health, perceived stress, blood/ injury/mutilation fear, and resilience were all significant predictors of depression in simple regression analyses. Our findings correspond with previous findings: recurrent exposure to traumatic stressors, such as death and the deceased can increase the likelihood of somatic symptoms (McCarroll et al., 2002). Mortuary workers are also more likely to worry about common, minor symptoms that are usually dismissed, which can lead to increased awareness of physical health status (McCarroll et al., 2002). We also found that female mortuary workers reported higher levels of somatic symptoms compared with men, and that forensic officers reported lower levels of somatic symptoms compared with other mortuary staff (e.g., administrative staff, cleaners). Greater somatization among women is consistent with findings from other epidemiologic and clinic-based studies (Barsky et al., 2001; Hiller et al., 2006; Matud, 2004; Nimnuan et al., 2001). Surprisingly, higher rates of somatization among women did not correspond with higher rates of depression and PTSD in the current study. The latter finding may, in part, be accounted for by the small sample size. Forensic officers reported lower levels of somatic symptoms compared with other mortuary staff. It may be hypothesized that the former group is less prone to somatization because of greater exposure to dead bodies, whereas the latter group is more prone to somatization on account of less exposure to dead bodies and a lack of proper training in dealing with this exposure, although this requires further investigation. Second, perceived stress has been identified as a predictor of higher levels of depression and anxiety among mortuary workers (Goldenhar et al., 2001). South African mortuary workers face unique challenges because of an overburdened health care system and a high burden of violence and injury-related deaths (Bradshaw et al., 2005). Often, mortuary workers have to inform the family of the deceased and provide basic counseling, for which they may lack professional skills (Brysiewicz, 2007; Ward et al., 2006a, 2006b). Their work environment and job demands may be perceived as highly stressful, with chronic situational exposure to stress associated with depression (Goldenhar et al., 2001; Ward et al., 2006a, 2006b). Third, fear of blood, bodily injury, and mutilation is a common phobia in general population studies and is associated with an increased risk for psychiatric disorders (Bienvenu and Eaton, 1998). Fear of blood/injury/mutilation is also related to physical health, owing to an increased risk of exposure to blood-borne pathogens in mortuaries (Goldenhar et al., 2001; Ogunnowo et al., 2012). Inexperienced mortuary workers had more blood/injury/mutilation fears and depression compared with experienced mortuary workers. Inexperienced health workers are more vulnerable to injuries and, therefore, exposure to contaminated blood (Kumakech et al., 2011; Reis et al., 2004; Shariati et al., 2007). Inexperienced mortuary workers may have greater blood/injury/ mutilation fear because of their increased vulnerability. The added anxiety related to starting a new job may have contributed to higher levels of depression in this group (Harris, 2001). Fourth, resilience is arguably a strong preventive factor against the development of depression. Individuals working in stressful environments with low levels of resilience may be at greater risk of developing mental illness (Edward, 2005). Social support, an important protective factor against the development of mental illness, is often compromised among mortuary workers. Death and mortality are topics that tend to
Depression Among Mortuary Workers
be avoided, and working with the deceased may lead to social ostracism, discrimination, and harassment, which may diminish job satisfaction, self-esteem, and self-worth, leaving an individual vulnerable to mental illness (Goldenhar et al., 2001; Patwary, 2010). In the current study, perceived stress was the only significant predictor of depression in multiple regression analysis. It is possible that perceived poor health, less resilience, and blood/injury/mutilation fears lead to a greater inability to cope with daily demands, higher levels of perceived stress, and depression (Goldenhar et al., 2001). Constant confrontation with human death and mortality may further increase the risk for depression (Patwary, 2010). Longitudinal tracking of the course of mental and physical health in mortuary workers will enhance our understanding of the causal contribution of perceived stress, blood/injury/ mutilation fears, physical health, and resilience to depression outcomes. ACKNOWLEDGMENTS The authors acknowledge and thank Celine Fjeldheim, Karin Pretorius, Marina Basson, and Karen Cloete for their contribution to this study. This work was supported by the South African Research Chairs Initiative in Posttraumatic Stress Disorder (Department of Science and Technology and the National Research Foundation) and the Medical Research Council on Anxiety and Stress Disorders. DISCLOSURES The authors declare no conflict of interest. REFERENCES Alexander DA, Klein S (2001) Ambulance personnel and critical incidents: Impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry. 178:76–81. Barsky AB, Peekna HM, Borus JF (2001) Somatic symptom reporting in women and men. J Gen Intern Med. 16:266–275. Basic Conditions of Employment Act (1997) (DOL) 23.1 (RSA). Bao Y, Sturm R, Croghan TW (2003) A national study of the effect of chronic pain on the use of health care by depressed persons. Psychiatr Serv. 54:693–697. Beaton R, Murphy S, Johnson C, Pike K, Corneil W (1998) Exposure to duty-related incident stressors in urban fire fighters and paramedics. J Trauma Stress. 11:821–828. Bennett P, Williams Y, Page N, Hood K, Woollard M (2004) Levels of mental health problems among UK emergency ambulance workers. Emerg Med J. 21:235–236. Bienvenu OJ, Eaton WW (1998) The epidemiology of blood-injury phobia. Psychol Med. 28:1129–1136. Bills CB, Levy NAS, Sharma V, Charney DS, Herbert R, Moline J, Katz CL (2008) Mental health of workers and volunteers responding to events of 9/11: Review of the literature. Mt Sinai J Med. 75:115–127. Bradshaw D, Nanna N, Groenewald P, Joubert J, Laubscher R, Nojilana B, Norman R, Pieterse D, Schneider M (2005) Provincial mortality in South Africa, 2000—Priority setting for now and a benchmark for the future. S Afr Med J. 95:496–503. Brysiewicz P (2007) The lived experience of working in a mortuary. Acc Emerg Nurs. 15:88–93. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav. 24:385–396. Cohen S, Williamson G (1988) Perceived stress in a probability sample of the United States. In Spacapan S, Oskamp S (Eds), The social psychology of health: Claremont symposium on applied psychology (pp 31–66). Newbury Park, CA: Sage. Connor KM, Davidson JR (2003) Development of a new resilience scale: The ConnorDavidson Resilience Scale. Depress Anxiety. 18:76–82.
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