Workplace stress associated with cardiovascular deaths

Study underscores the health threats of workplace pressures

Occupational health professionals have been aware for years of the deleterious impact stress can have on employee health. However, a new study in the October 2002 issue of BMJ (formerly the British Medical Journal) brings the issue into sharp focus with some disturbing findings, and perhaps indicates a need to redouble efforts to combat workplace stress.

The researchers concluded that workers with high stress levels may be more than twice as likely to die of cardiovascular disease than co-workers who do not share the same stress levels. In a study that followed more than 800 Finnish industrial workers for more than 25 years, they found that "after adjustment for age and sex, employees with high job strain [a combination of high demands at work and low job control] had a 2.2-fold cardiovascular mortality risk compared with their colleagues with low job strain. The corresponding risk ratio for employees with effort-reward imbalance [low salary, lack of social approval, and few career opportunities relative to efforts required at work] was 2.4."1

They also found that high job strain was associated with increased serum cholesterol at the five-year follow-up, and that effort-reward imbalance predicted increased body mass index at the 10-year follow-up. While the researchers noted that there is a large body of research employing the job strain and effort-reward imbalance models, "No previous study has tested them simultaneously in relation to cardiovascular mortality."

Nothing new, but . . .

While occupational health experts were not surprised by the findings, some were impressed. "It’s not a new thought and studies have looked at this link before, but this could very well be a better, more convincing study," says Jeffrey P. Kahn, MD, a New York City psychiatrist and business consultant at He is also co-editor of a new book, Mental Health & Productivity in the Workplace. However, he continues, "we need to be more open-minded than [the researchers] are, although what they say is quite believable."

If you look at recognized, statistical risk factors for heart disease, it doesn’t necessarily mean those factors cause heart disease, says Kahn. "For example, earlobe creases seem to be a risk factor for heart disease, but no one suggests you do plastic surgery to end the risk." Nevertheless, he says, "There are a number of factors that seem to have to do with heart disease, depending on which data you believe. This study presents one. There’s also other literature showing some relationship between depression, anxiety disorders, and heart disease."

There’s certainly nothing new in the correlation between stress and heart disease, adds Don R. Powell, PhD, president of the American Institute for Preventive Medicine in Farmington Hills, MI. "The theory seems to be that when you are under stress, it creates a striation of the blood vessels. Because the lining of the vessels is no longer smooth, cholesterol is more likely to adhere to arterial walls."

Where do employers stand?

When cable news networks such as CNN give airtime to studies like the one in BMJ, it’s hard for company executives to ignore the issue. That doesn’t mean, however, that they will give workplace stress the attention it merits. "Companies should certainly not be surprised [about the issue] given the relatively strong link in the literature between stress and cardiovascular disease," notes Sam Moon, MD, MPH, chief of the division on environmental and occupational medicine, and director of clinical and corporate affairs for the Duke Center for Integrated Medicine in Durham, NC.

Nevertheless, he adds, "companies are all over the board. Some companies don’t see [workplace stress] as part of their responsibility, like they do complying with OSHA standards. The place it does come into play is with companies that look more globally at the health of the work force."

"Certainly, workplaces need to address stress, but in the past, some workplaces didn’t even want to admit there was any stress because of the potential for workers’ comp claims," says Powell. "They felt they might be held liable for stress in the workplace, just as they can be for having hazardous materials and dangerous equipment or having poor ergonomic practices lead to carpal tunnel syndrome."

Kahn has had similar experiences. "A few years ago, the head of human resources for a large corporation asked me to make a presentation about substance abuse to senior management," he recalls. "The program was scheduled, but the CEO heard about it and cancelled it on the grounds that there was no substance abuse problem at his company. That’s not so uncommon."

Powell sees a shift, however, not only because stress has been so closely associated with heart disease, but also because it can lead to increased costs and decreased productivity. "Employees under stress make mistakes that can be costly to the company — in extreme cases, they can even go on a killing rampage," he notes. "More than before, companies are now dealing with stress either through their EAPs [employee assistance programs], occupational health programs, or wellness programs."

Kahn is not nearly as sanguine. "I think most employers don’t know how to take it seriously," he says. "Stress management programs are fairly common, but there is little evidence they do much good. The employees who participate are likely not to be the most stressed." Kahn says that when he conducts workplace seminars, he always asks the attendees to think of the five most stressed people in the company, and look around the room and raise their hands to indicate how many they see. "I’ve never seen any hands," he relates. Not only are stress management programs not as effective as they might be in reaching the people who need help the most, says Kahn, "But beyond that, we are not necessarily using the most effective approaches."

New approaches emerging

New approaches to stress management will hopefully prove more effective, thus strengthening employer commitment. Of course, there may be numerous paths to the same goal. For Kahn, any successful approach must have two key elements: 1) the ability to identify those employees who will benefit from the right kinds of help (e.g., via self-assessment questionnaires); 2) the ability to provide those employees with the right kind of help. "There are a number of strategies that can be used, but the most effective have not been tried," he asserts. He is currently working with a large company on developing a national program to do a better job of identifying workers who need help.

Kahn is interested in those workers who are what he calls seriously distressed. "They have lots of things going on in their lives at the same time — a promotion, a new child, a mother who recently died," he explains, noting that events don’t have to be negative to add to stress levels.

For Moon, one of the newest wrinkles in stress management is what he calls "a higher level of EAPs." His group at Duke has perhaps the largest mental occupational health practice in the country. "We have psychologists who just focus on work health," he explains. The program also has post- doc fellowships, which were kicked off with money from the National Institute for Occupational Safety and Health. "We not only provide confidential visits to workers — which is a critical part of stress reduction; having someone to talk with — but we go farther, by helping to identify important organizational trends," says Moon.

Often the first sign of problems appears when employees come forward because they have symptoms of stress — they may not be sleeping well, or they have problems concentrating. "While the individual problem is confidential, you still have a conduit to feed back general trends to the organization," he explains.

This approach helps address what Moon sees as one of the most critical issues of stress management. "Whose responsibility is stress?" he posits. "Does the hazard reside with the employee or with the job? Or does it reside in the interaction between the two — which I believe. We in occupational health usually assign responsibility to one or the other."

It is important for occupational health professionals, he says, to look at work, health, and productivity in an overall framework. "You have to look at long- and short-term disability, workers’ comp — all elements — to really get a handle on things," says Moon. "Companies that do that often put much effort into wellness, and a good portion of that will focus on stress reduction."

For Powell, cognitive restructuring is an important new technique, which he has incorporated into his program, Systematic Stress Management. "It helps people look at the stresses around them and then analyze what they are saying to themselves — their attitudes and beliefs about those stressors," he explains. "That’s really the determining factor; nothing is inherently good or bad. What if you have an accident on the way to work? One employee might think about how their beautiful car was scratched, and experience a full-blown stress reaction and have a bad day. Another could total their car, but be happy because they are safe and sound." People can be taught to make changes in their attitudes and belief systems, Powell asserts.

Social support is another new area Powell is exploring. "Research shows people who are isolated and on their own have more stress than those involved with social groups and who have a sense of connectedness," he observes. "Some companies will actually put together support groups for people in stress or refer them to community organizations."

Whatever methods you employ, it’s important to recognize that not doing the job properly or completely can be costly, says Kahn. "There is a definite financial advantage to doing it right the first time," he notes. "You can offer limited benefits to some people, a show of goodwill to employees, but you don’t necessarily get at the underlying organizational problems, personality problems, professional problems — some of which the company may not want to get at. But there’s a clear disadvantage to not addressing the problem as well as you’d like.

"The trick is to address the root causes in a way that will not only provide benefits for the employees but for the company," he continues. "Studies show that if you do a program right and provide good treatment, there is a substantial cost offset in saved medical costs, reduced turnover and absenteeism, and increases in productivity."


1. Kivimaki M, Leino-Arjas P, Luukkonen R, et al. Work stress and risk of cardiovascular mortality: Prospective cohort study of industrial employees. BMJ 2002; 325:857.

For more information contact:

Jeffrey P. Kahn, MD, WorkPsych Associates, New York City. Telephone: (212) 362-4099. E-mail:

Sam Moon, MD, MPH, Chief, division of environmental and occupational medicine, Duke Center for Integrated Medicine, P.O. Box 3834, Duke University Medical Center, Durham, NC 27710. Telephone: (919) 286-3232.

Don R. Powell, PhD, American Institute for Preventive Medicine, 30445 Northwestern Highway, Suite 350, Farmington Hills, MI. Telephone: (248) 539-1806. Fax: (248) 539-1808.