BEU, Alm.del - 2020-21 - Bilag 7: Orientering om artikel fra NFA om sammenhængen mellem seksuel chikane på arbejdet og efterfølgende øget risiko for depressive lidelser, fra beskæftigelsesministeren

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Journal of Affective Disorders 277 (2020) 21–29

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ScienceDirect

Journal of Aﬀective Disorders

journal homepage:

www.elsevier.com/locate/jad

Research paper

Onset of workplace sexual harassment and subsequent depressive symptoms

and incident depressive disorder in the Danish workforce

Reiner Rugulies

a,b,c,

, Kathrine Sørensen

, Per T. Aldrich

, Anna P. Folker

, Maria K. Friborg

Susie Kjær

, Maj Britt D. Nielsen

, Jeppe K. Sørensen

, Ida E.H. Madsen

⁎

National Research Centre for the Working Environment, Copenhagen, Denmark

Department of Public Health, University of Copenhagen, Denmark

Department of Psychology, University of Copenhagen, Denmark

Joblife, Allerød, Denmark

National Institute of Public Health, University of Southern Denmark, Denmark

Anerkendende Psykologpraksis, Herlev, Denmark

A R T I C LE I N FO

Keywords:

Depression

Occupational Health

Psychosocial Work Environment

Stress

Violence

Oﬀending Behaviours

A B S T R A C T

Background:

We studied onset of workplace sexual harassment and subsequent risk of depressive symptoms and

depressive disorder.

Methods:

We examined 9,981 individuals who participated in the Work Environment and Health in Denmark

survey in 2012 and 2014 and 6,647 individuals who also participated in 2016, all unexposed to sexual har-

assment in 2012. Depressive symptoms and disorder were assessed with the Major Depression Inventory. Using

linear regression, we estimated the associations between onset of sexual harassment in the 12 months preceding

the 2014 survey and depressive symptoms in 2014 and 2016, respectively. Using logistic regression, we esti-

mated risk of incident depressive disorder in 2014.

Results:

Onset of sexual harassment was associated with elevated depressive symptoms in 2014, both for har-

assment by non-workplace personnel (e.g., patients, estimate (B): 1.61, 95% CI: 0.51–2.72,

= 0.004) and

workplace personnel (e.g., supervisors, B: 3.85, 95% CI: 2.51–5.20,

< 0.001), after adjustment for depressive

symptoms in 2012. Harassment by workplace personnel was further associated with elevated depressive

symptoms in 2016 after adjustment for symptoms in 2012, but not after adjustment for symptoms in 2014.

Harassment by workplace personnel was associated with incident depressive disorder in 2014 (odds ratio: 5.26,

95% CI: 2.68–10.31,

< 0.001).

Limitations:

Depressive symptoms and disorder were assessed with a validated self-administered rating scale but

not a clinical diagnostic interview. Participants reporting harassment in 2014 had elevated depressive symptoms

already in 2012 requiring future investigation.

Conclusions:

Exposure to sexual harassments at the workplace may be a contributing factor in the aetiology of

depressive symptoms and disorder.

1. Introduction

Sexual harassment at work has become a topic of rapidly increasing

interest, not least because of the #MeToo debate, where well-known

individuals from the entertainment and professional sports industry and

from politics were accused of sexual harassment (Choo

et al., 2019;

Freischlag and Faria, 2018; Mendes et al., 2018).

While the debate

showed a broad societal consensus that workplace sexual harassment is

unacceptable and is thought to be psychological harmful for those ex-

posed to sexual harassment (O'Neil

et al., 2018),

epidemiological

studies of high quality quantifying the impact of workplace sexual

harassment on mental health outcomes are scarce (McDonald,

2012;

O'Neil et al., 2018; Quick and McFadyen, 2017; Sojo et al., 2016;

Spector et al., 2014; Willness et al., 2007).

Reviews of the literature have shown that the vast majority of stu-

dies examining the association of workplace sexual harassment and risk

of mental ill-health have been cross-sectional in design, severely lim-

iting any conclusion about the causal direction of the association

(McDonald,

2012; Sojo et al., 2016; Spector et al., 2014; Willness et al.,

2007).

One of the few exceptions is a longitudinal study with 1775

⁎

Corresponding author at: National Research Centre for the Working Environment, Lerso Parkalle 105, DK-2100 Copenhagen, Denmark.

E-mail address:

[email protected]

(R. Rugulies).

https://doi.org/10.1016/j.jad.2020.06.058

Received 20 January 2020; Received in revised form 16 May 2020; Accepted 16 June 2020

Available online 15 July 2020

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

BEU, Alm.del - 2020-21 - Bilag 7: Orientering om artikel fra NFA om sammenhængen mellem seksuel chikane på arbejdet og efterfølgende øget risiko for depressive lidelser, fra beskæftigelsesministeren

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Norwegian employees, reporting a two-fold higher risk of psychological

distress symptoms among women, but not among men, following ex-

posure to sexual harassment in a two-year follow-up study (Nielsen

and

Einarsen, 2012).

To the best of our knowledge, no longitudinal study

has examined yet, whether workplace sexual harassment predicts ele-

vated depressive symptoms or the incidence of a depressive disorder.

Although longitudinal studies have the obvious advantage over

cross-sectional studies that they allow examining the temporal order in

the association between the exposure to sexual harassment and sub-

sequent mental health, they also face important challenges. In a long-

itudinal study, researchers usually would examine if sexual harassment

at baseline predicts depressive symptom level at follow-up, after ad-

justment for baseline depressive symptom level. On the one hand, ad-

justing for baseline depressive symptom level is an appropriate ap-

proach, because baseline depressive symptom level may inﬂuence both

the reporting of baseline sexual harassment and depressive symptom

level at follow-up, causing spurious associations between baseline

sexual harassment and depressive symptom level at follow-up. On the

other hand, adjusting for baseline depressive symptom level would be

inappropriate if the eﬀect of sexual harassment on depressive symptoms

is instantaneous, i.e. without any considerable latency period. In this

case, baseline sexual harassment would inﬂuence baseline depressive

symptom level and adjusting for baseline depressive symptom levels

would be an adjustment for an earlier manifestation of the eﬀect,

leading to an underestimation of the association between baseline

sexual harassment and depressive symptom level at follow-up.

To address the challenge that baseline depressive symptoms might

be inﬂuenced by baseline sexual harassment, we constructed a cohort of

workers where no one was exposed to sexual harassment at baseline.

We then followed this cohort for two years and during this time some of

the participants reported being exposed to sexual harassment. We then

analysed both the association between the onset of exposure to sexual

harassment and subsequent depressive symptoms and incident depres-

sive disorder, while adjusting for participants’ depressive symptoms at

baseline, when they were unexposed.

We had previously reported cross-sectional results on sexual har-

assment and depressive symptoms in a subsample of our study popu-

lation (Friborg

et al., 2017).

These results indicated that the strengths of

the association between sexual harassment and mental health might

depend on the type of the perpetrator (Friborg

et al., 2017).

Conse-

quently, we distinguished in the present study between harassment by

non-workplace personnel (customers, clients, patients, students) and by

workplace personnel (colleagues, supervisors, subordinates).

2. Methods

2.1. Study design and population

two study designs.

Fig. 2

shows the

ﬂow-chart

for inclusion into the study and con-

structing the two cohorts. A detailed description of the WEHD study

design and recruitment process is published elsewhere (Johnsen

et al.,

2019).

Brieﬂy, in 2012, Statistics Denmark drew a nationwide sample

of 35,039 employees, aged 18 to 64 years, of which 17,622 (50.3%)

responded to the WEHD 2012 questionnaire (t1). We excluded re-

spondents who were not in the workforce when they

ﬁlled

in the

questionnaire (n = 950), had missing values on key variables (n = 865)

or were exposed to sexual harassment at t1 (n = 412), yielding a

sample of 15,435 individuals. Of those, 9981 responded to the follow-

up questionnaire in 2014 (t2), were at work at t2 and had no missing

values on key variables. These individuals constituted cohort I for

analysing the short-term association between onset of sexual harass-

ment in the 12 months before t2 and level of depressive symptoms at t2.

For analysing risk of incident depressive disorder at t2, we built a

subsample of cohort I by excluding 972 individuals who at t1 had signs

of a depressive disorder (n = 485), reported treatment for a depressive

disorder during the last year (n = 359), or both (n = 128), yielding a

subsample of 9009 individuals who were free of a depressive disorder at

baseline.

Of the 9981 participants of cohort I, 6647

ﬁlled

in the WEHD 2016

survey (t3) with no missing values on key variables. These individuals

constituted cohort II for analysing the long-term association between

onset of sexual harassment in the 12 months before t2 and level of

depressive symptoms at t3.

2.2. Assessment of workplace sexual harassment

Workplace sexual harassment was assessed with one question:

“Have

you been exposed to sexual harassment at your workplace during

the last 12 months?”, with the response options

“yes,

daily”,

“yes,

weekly”,

“yes,

monthly”,

“yes,

rarely”,

“no,

never”. For the purpose of

analysis, we collapsed all

“yes”

options together, generating a binary

variable indicating presence or absence of sexual harassment.

Participants who selected one of the

“yes”

options were then asked

“Who

exposed you to sexual harassment?”, with the response options

“customer/client/patient/student/others”

(non-workplace person-

nel),“colleague”,

“supervisor”,

“subordinate”

(workplace personnel).

We constructed three exposure groups according to exposure in

2014 (t2): Group 1 was not exposed to sexual harassment, Group 2 was

exposed to sexual harassment by non-workplace personnel and Group 3

was exposed to sexual harassment by workplace personnel. If an in-

dividual was exposed to sexual harassment by both non-workplace

personnel and workplace personnel then this individual was assigned to

Group 3.

2.3. Measurement of depressive symptoms and disorder

We used data from the Work Environment and Health in Denmark

(WEHD) study, a bi-annual survey on working conditions and health

established in 2012. We examined the association between onset of

workplace sexual harassment and subsequent level of depressive

symptoms and incident depressive disorder in the Danish workforce

with measurements in 2012 (t1), 2014 (t2) and 2016 (t3). All partici-

pants were free of sexual harassment at t1 and the 12 months preceding

t1. At t2, some participants reported the onset of at least one episode of

sexual harassment during the last 12 months. Based on this information

we constructed two cohorts. In

cohort I

(participants with measure-

ments in 2012 and 2014) we analysed the association between onset of

sexual harassment in the 12 months before t2 and depressive symptoms

and disorder at t2 (short-term association).

In cohort II

(participants

with measurements in 2012, 2014, and 2016) we analysed the asso-

ciation between onset of sexual harassment in the 12 months before t2

and depressive symptoms at t3 (long-term association). In both cohorts

we adjusted the analyses for depressive symptom level at t1 when all

participants were unexposed to sexual harassment.

Fig. 1

illustrates the

We measured depressive symptoms and disorder by the Major

Depression Inventory (MDI), a clinically validated self-administered

rating scale (Bech

et al., 2001, 2015; Olsen et al., 2003).

The MDI

consists of 12 items assessing the presence of depressive symptoms

during the last two weeks in accordance with the ICD-10 symptom list

of depression (Bech

et al., 2001).

Each item is responded on a scale

ranging from 0 (the symptom has not been present at all) to 5 (the

symptom has been present all of the time). Two pairs of items are

combined (i.e. only the item with the higher score is included), yielding

an MDI-score with a possible range of 0 to 50 points. We used this score

for assessing the level of depressive symptoms in our study. As an in-

dicator for the presence of a depressive disorder we used a MDI-score of

≥21

points as recommended in a recent validation study of the MDI

(Bech

et al., 2015).

In addition to the MDI, the survey included also a question whether

the respondent was currently or in the last year in treatment for a de-

pressive disorder, with the response options

“yes”

“no”.

We used this

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Fig. 1.

Illustration of the design and measurement points of the two cohort studies.

response as further information for identifying a prevalent depressive

disorder at baseline.

2.4. Measurement of covariates

As covariates we included age (continuous, in years), sex, cohabi-

tation (yes/no), education (“low” (≤10 years of education),

“medium-

low” (10–12 years),

“medium

high” (13–15 years) and

“high”

(≥15

years)), and occupational status (“senior manager”,

“working

in a job

requiring high skill level”,

“working

in a job requiring intermediate skill

level”,

“working

in occupation requiring basic skill level”,

“other

jobs/

not classiﬁed”). All these covariates were derived from national regis-

ters maintained by Statistics Denmark, using the participants’ unique

civil registration number (Pedersen,

2011).

We further included a

variable indicating the occupational sector, by using the codes of the

Danish version of the EU's nomenclature (NACE, Statistical classiﬁca-

tion of economic activities in the European Community) from Statistics

Denmark (Torma

et al., 2007).

We used

“the

standard industrial

grouping for publishing purposes” that aggregates the 726 possible

industries into 10 groups (Torma

et al., 2007).

2.5. Statistical analysis

Using linear regression and logistic regression, respectively, we

compared the level of depressive symptoms and the proportion of in-

dividuals with incident depressive disorder at follow-up in the two

exposed groups (onset of sexual harassment by non-workplace per-

sonnel; onset of sexual harassment by workplace personnel) to the level

and proportion in the reference group (no onset of sexual harassment).

In cohort I, we compared levels of depressive symptom scores at t2

in the three groups, yielding estimates for the mean diﬀerences with

95% conﬁdence intervals (CI) for the short-term association between

onset of exposure to sexual harassment during the last 12 months before

t2 and level of depressive symptoms at t2.

In the subsample of cohort I that was free of a depressive disorder at

t1, we compared the proportion of individuals with incident depressive

disorder at t2 in the three groups, yielding odds ratios (OR) with 95% CI

for the short-term association between onset of sexual harassment

during the last 12 months before t2 and risk of incident depressive

disorder at t2.

All estimates from cohort I were adjusted for age, sex, cohabitation,

education, occupational status, occupational sector and depressive

symptom level at t1.

In cohort II, we compared levels of depressive symptom scores at t3

in the three groups, yielding estimates for the mean diﬀerences with

95% CI for the long-term association between onset of sexual harass-

ment during the last 12 months before t2 and level of depressive

symptoms at t3. In model 1, estimates were adjusted for age, sex, co-

habitation, education, occupational status, occupational sector, de-

pressive symptom level at t1 and treatment for a depressive disorder at

t1. In model 2, estimates were further adjusted for depressive symptom

level at t2 and treatment for a depressive disorder at t2. Because some

individuals who were free of sexual harassment at t2 became exposed to

harassment in the 12 months before t3, we conducted an additional

analyses of cohort II, in which we excluded those newly exposed par-

ticipants.

3. Results

Table 1

shows the characteristics of the participants of the two co-

horts. Mean age was 46 years in cohort I and 47 years in cohort II.

Women and men were almost equally represented in the study (53%

women in both cohorts). Most participants worked in public adminis-

tration, education and health (41 and 42% in cohort I and II, respec-

tively), followed by trade and transport (17% in both cohorts).

Onset of sexual harassment in the 12 months before t2 was reported

by 175 participants in cohort I (1.75%) and 103 individuals in cohort II

(1.55%). The majority of the participants reported that the exposure

was

“rarely”

(146 out of 175 (83.43%) and 87 out of 103 (84.47%) in

cohorts I and II, respectively). The perpetrator came more often from

non-workplace personnel than from workplace personnel (105 out of

175 (60.00%) and 67 out of 103 cases (65.05%) in cohorts I and II

respectively).

Women reported more sexual harassment than men. In cohort I,

harassment from non-workplace personnel was reported by 1.80% of

women (95 out of 5281) and 0.21% of men (10 out of 4700).

Harassment from workplace personnel was reported by 0.78% of

women (41 out of 5281) and 0.62% of men (29 out of 4700). In cohort

II, harassment from non-workplace personnel was reported by 1.69% of

women (60 out of 3543) and 0.23% of men (7 out of 3104). Harassment

from workplace personnel was reported by 0.73% of women (26 out of

3543) and 0.32% of men (10 out of 3104).

3.1. Onset of sexual harassment in the 12 months before t2 and depressive

symptoms at t2 (short-term association)

Fig. 3

shows changes in depressive symptom levels from t1 to t2 in

the three groups from cohort I. Groups 2 and 3 consisting of partici-

pants who later became exposed to sexual harassment had already at t1

higher depressive symptom levels than the reference group that not

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Fig. 2.

Flow-chart of the construction of cohort I and cohort II.

became exposed.

From t1 to t2, depressive symptom levels remained stable among

those who remained unexposed to sexual harassment (Group 1, change

−0.07

points) and increased among those who became exposed to

sexual harassment by non-workplace personnel (Group 2, +0.94

points) and workplace personnel (Group 3, +2.49 points).

Consequently, at t2, depressive symptom levels were statistically sig-

niﬁcantly higher among participants exposed to sexual harassment by

both non-workplace personnel (Group 2, mean: 11.17, SD: 7.98, esti-

mate (B): 1.61, 95% CI: 0.51 to 2.72,

= 0.004) and workplace per-

sonnel (Group 3, mean: 14.49, SD: 9.97, B: 3.85, 95% CI: 2.51 to 5.20,

< 0.001) compared to participants that were not exposed (Group 1,

mean: 7.64, SD: 7.25) after adjustment for all covariates, including

depressive symptom level at t1.

When we stratiﬁed the analyses by sex, there was no clear indication

that the short-term association between sexual harassment and de-

pressive symptoms may be diﬀerent for women and men (see

e-Table

Online appendix).

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Table 1

Characteristics of the two cohorts in 2014.

Cohort I (2012–2014)

= 9981

Age,

mean (SD)

Sex

Women,

(%)

Men,

(%)

Cohabitation

Yes,

(%)

Education

High,

(%)

Medium high,

(%)

Medium low,

(%)

Low,

(%)

Not known,

(%)

Occupational Status

Senior manager,

(%)

Job requiring high skill level,

(%)

Job requiring intermediate skill level,

(%)

Job requiring basic skill level,

(%)

Other/not classiﬁed,

(%)

Occupational Sector

Agriculture, forestry and

ﬁshing,

(%)

Manufacturing, mining, quarrying, utility services,

(%)

Construction,

(%)

Trade and transport,

(%)

Information and communication,

(%)

Financial and insurance,

(%)

Real estate,

(%)

Other business services,

(%)

Public administration, education and health,

(%)

Arts, entertainment, other services,

(%)

Sexual harassment

Never,

(%)

Rarely,

(%)

Monthly or more often,

(%)

Perpetrator for sexual harassment

Group 1: No harassment

Group 2: Harassment by non-workplace personnel,

(%) (Client, Customer, Patient, Student)

Group 3: Harassment by workplace personnel,

(%) (Colleague, Supervisor, Subordinate)

46.26 (10.23)

5281 (52.91)

4700 (47.09)

7985 (80.00)

1375 (13.78)

3196 (32.02)

4225 (42.33)

1134 (11.36)

51 (0.51)

483 (4.84)

2312 (23.16)

2458 (24.63)

3078 (30.84)

1650 (16.53)

100 (1.00)

1369 (13.72)

368 (3.69)

1718 (17.21)

379 (3.80)

406 (4.07)

160 (1.60)

953 (9.55)

4124 (41.32)

404 (4.05)

9806 (98.25)

146 (1.46)

29 (0.29)

9806 (98.25)

105 (1.05)

70 (0.70)

Cohort II (2012–2014–2016)

= 6647

46.69 (9.38)

3543 (53.30)

3104 (46.70)

5414 (81.45)

937 (14.10)

2170 (32.65)

2792 (42.00)

721 (10.85)

27 (0.41)

301 (4.53)

1587 (23.88)

1704 (25.64)

2018 (30.36)

1037 (15.60)

67 (1.01)

918 (13.81)

229 (3.45)

1128 (16.97)

260 (3.91)

261 (3.93)

98 (1.47)

629 (9.46)

2771 (41.69)

286 (4.30)

6544 (98.45)

87 (1.31)

16 (0.24)

6544 (98.45)

67 (1.01)

36 (0.54)

3.2. Onset of sexual harassment in the 12 months before t2 and incident

depressive disorder at t2 (short-term association)

Of the 9009 participants who were free of a depressive disorder in

2012, 355 (3.9%) were classiﬁed with a depressive disorder in 2014.

The incidence rate of depressive disorder was 3.8%, 9.8% and 25.0% in

Groups 1, 2 and 3, respectively.

Table 2

shows the odds ratios and 95%

CI for the association between onset of sexual harassment and incident

depressive disorder. Compared to the reference group with no exposure

to sexual harassment (Group 1), the odds ratio for incident depressive

disorder was 1.92 (95% CI: 0.88 to 4.19,

= 0.10) among participants

exposed to sexual harassment by non-workplace personnel (Group 2),

and 5.26 (95% CI: 2.68 to 10.31,

< 0.001) among participants ex-

posed to sexual harassment by workplace personnel (Group 3) after

adjustment for all covariates, including depressive symptom level at t1.

3.3. Onset of sexual harassment in the 12 months before t2 and depressive

symptoms at t3 (long-term association)

Fig. 4

shows changes in depressive symptom levels from t1 to t2 to

t3 for the three groups from cohort II. As in cohort I, also cohort II

participants who later became exposed to sexual harassment (Group 2

and 3) had already at t1 higher depressive symptom levels than parti-

cipants who not later became exposed (Group 1).

From t1 to t3, depressive symptom levels remained stable in the

non-exposed group (Group 1, +0.04 points) and increased for partici-

pants who became exposed to sexual harassment by non-workplace

personnel (Group 2, +0.24 points) and workplace personnel (Group 3,

+1.80 points). At t3, depressive symptom levels were statistically

signiﬁcantly higher among participants exposed to sexual harassment

by workplace personnel (Group 3, mean: 12.22, SD: 9.92, B: 2.54, 95%

CI: 0.62 to 4.46,

= 0.01) compared to participants that were not

exposed (Group 1, mean: 7.64, SD: 7.25) after adjustment for covari-

ates, including depressive symptom level at t1 and treatment for de-

pressive disorder at t1 (model 1). After further adjustment for depres-

sive symptom level at t2 and treatment for a depressive disorder at t2,

the estimate attenuated and statistical signiﬁcance was lost (model 2,

= 0.22). Group 2 did not diﬀer statistical signiﬁcantly in depressive

symptom levels at t3 from Group 1, neither in the analyses in model 1

(p = 0.29) nor in model 2 (p = 0.93).

When we stratiﬁed the analyses by sex, there was no clear indication

that the long-term association between sexual harassment and depres-

sive symptoms may be diﬀerent for women and men (see

e-Table

Online appendix).

When we excluded participants, who were not exposed to sexual

harassment in the 12 months preceding t2 (Group 1) but became ex-

posed in the 12 months preceding t3, results were similar to the main

analyses (data available upon request).

4. Discussion

4.1. Interpretation of the results

The results of this study of the Danish workforce show that onset of

workplace sexual harassment, particularly from workplace personnel,

was associated with elevated depressive symptoms and risk of incident

depressive disorder. Particularly striking was the

ﬁve-fold

higher risk of

incident depressive disorder among participants exposed to onset of

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Fig. 3.

Short-term association between onset of sexual harassment in the 12 months before t2 and depressive symptom level at t2 among 9981 women and men who

were not exposed to sexual harassment at t1.

sexual harassment by workplace personnel compared to those who re-

mained unexposed, after adjustment for baseline depressive symptom

level (short-term association analysis).

That the association between sexual harassment and depressive

symptoms and disorder was stronger when the harassment came from

workplace personnel, such as a colleague or supervisor, and weaker

when harassment came from non-workplace personnel, such as a cus-

tomer, client or patient, is in agreement with results from an earlier

cross-sectional analysis conducted in a subsample of our study popu-

lation (Friborg

et al., 2017).

Sexual harassment by colleagues or su-

pervisors may be experienced as particularly adverse as it is often ne-

cessary to collaborate with the perpetrator on a daily basis, which may

be emotionally taxing. Further, revealing the sexual harassment at the

workplace may sometimes negatively change the social relations to

other colleagues and supervisors, which could be a further source of

emotional strain.

Sexual harassment by non-workplace personnel often includes har-

assment by individuals who may not be responsible for their behavior,

such as eldercare home residents with dementia or institutionalized

individuals with severe mental health conditions (Nielsen

et al., 2017).

A recent qualitative interview study showed that care workers often

consider handling sexual harassment by patients and clients as a mark

of professionalism (Nielsen

et al., 2017).

Further, at workplaces with a

relatively high prevalence of sexual harassment by non-workplace

personnel, employees might get habituated to the exposure to a certain

extent, and those employees who

ﬁnd

it diﬃcult to get habituated

Table 2

Short-term association between onset of sexual harassment in the 12 months before t2 and risk of incident depressive disorder at t2 among 9009 women and men who

were at t1 both free of a depressive disorder and not exposed to sexual harassment.

Group 1; No sexual harassment

Group 2; Sexual harassment by non-workplace personnel

Group 3; Sexual harassment by workplace personnel

8871

Cases (%)

333 (3.75%)

8 (9.76%)

14 (25.00%)

Crude

OR (95%CI)

1 Reference

2.77 (1.33–5.80)

8.55 (4.62–15.80)

Adjusted

OR (95%CI)

1 Reference

1.92 (0.88–4.19)

5.26 (2.68–10.31)

Logistic regression analysis. Estimates are adjusted for age, sex cohabitation, education, occupational status, occupational sector and, depressive symptom score at t1.

Individuals with indications of depressive disorder at t1 (either MDI-score

≥21

or self-reported treatment of depressive disorder at t1 or the year before t1) were

excluded.

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Fig. 4.

Long-term association between onset of sexual harassment in the 12 months before t2 and depressive symptom level at t3 among 6647 women and men who

were not exposed to sexual harassment at t1.

might not last long at the workplace and in the profession

(Nielsen

et al., 2017).

That all said, it is important to note that although

the association of sexual harassment with depressive symptoms was

weaker for harassment by non-workplace personnel than by workplace

personnel, also harassment by non-workplace personnel predicted an

elevated level of depressive symptoms that was statistically signiﬁcant.

Thus, sexual harassment by non-workplace personnel is by no mean

harmless, but it is likely qualitatively diﬀerent and maybe harmful to a

lesser extent compared to sexual harassment by workplace personnel.

We adjusted all estimates for depressive symptoms in 2012 (t1)

when all participants were unexposed to sexual harassment. Exposure

to sexual harassment between 2012 and 2014 was assessed in 2014 (t2)

by asking participants if they had been exposed to sexual harassment

during the last 12 months. Thus, our analyses showed the association

between a relatively recent onset of exposure to sexual harassment and

subsequent depressive symptoms and disorder, while adjusting for de-

pressive symptom level before onset of exposure. We believe that this

approach, adjusting for baseline depressive symptom level before the

onset of exposure had occurred, is superior to a traditional longitudinal

design that would have adjusted for baseline depressive symptoms

measured concurrently with the measurement of exposure, as it is

plausible that in the traditional design the baseline depressive symp-

toms already had been impacted by the prevalent exposure.

A disadvantage of our approach, though, is that we asked the par-

ticipants to recall the occurrence of sexual harassment during the last

12 months at the same time in 2014 when we also assessed depressive

symptoms and disorder. We cannot rule out that an unknown number of

study participants developed elevated depressive symptoms from 2012

to 2014 for other reasons than onset of workplace sexual harassment

and that these elevated depressive symptoms in 2014 had led them to

overestimate exposure to sexual harassment during the last 12 months.

We followed participants further until 2016 (t3), analyzing the as-

sociation between onset of sexual harassment in the 12 months before

2014 (t2) with depressive symptoms in 2016 (t3). For participants re-

porting harassment by workplace personnel, we still found an associa-

tion between harassment and depressive symptoms in 2016 (t3) after

adjustment for depressive symptoms in 2012 (t1). However, the asso-

ciation, was attenuated and lost statistical signiﬁcance after adjustment

for depressive symptoms in 2014 (t2). This was unsurprising, as we had

expected that the impact of exposure to sexual harassment in the 12

months preceding the 2014 (t2) survey on depressive symptoms would

be mainly seen in higher depressive symptoms in 2014 (t2) and that a

further increase in depressive symptoms from 2014 (t2) to 2016 (t3)

was unlikely.

An unexpected result of our study was that individuals who reported

onset of sexual harassment in the 2014 survey, already in 2012, when

they were unexposed, had higher depressive symptom levels compared

to participants who were unexposed in both 2012 and 2014. Diﬀerent

explanations for this result are conceivable. First, individuals with

elevated depressive symptoms may, for reasons unknown, be at higher

risk for becoming exposed to sexual harassment, suggesting that the

association between sexual harassment and depressive may be bi-

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

directional. Second, elevated depressive symptoms may make in-

dividuals more likely to perceive certain behaviors as sexual harass-

ment. Third, some individuals may have been exposed to sexual har-

assment in the more distant past, i.e. longer than the 12 months before

t1 that we assessed with our questionnaire and this history of previous

sexual harassment may have inﬂuenced both the level of depressive

symptoms at t1 and the risk of onset of sexual harassment at t2. Fourth,

speciﬁc adverse working conditions, e.g., conﬂicts at work or poor so-

cial relations among employees and between employees and manage-

ment, may contribute to a higher risk of both onset of sexual harass-

ment and elevated depressive symptoms. These potential explanations

are important topics to be examined in future studies. For the present

study, it was key that we had the data on depressive symptoms in 2012

(t1) available, and that we therefore were able to adjust all analyses for

depressive symptoms prior onset of exposure.

4.2. Comparison with earlier studies

To the best of our knowledge, our study is the

ﬁrst

one that ex-

amined the longitudinal association between onset of workplace sexual

harassment and risk of elevated depressive symptoms and disorder.

Further, we believe that our study is also the

ﬁrst

to examine sexual

harassment and depressive symptoms and disorder in a large cross-oc-

cupational sample of a national workforce, with repeated measure-

ments of both exposures and outcomes.

Cross-sectional associations between sexual harassment and symp-

toms of mental-ill health and reduced psychological well-being have

been documented in several previous studies (McDonald,

2012;

Sojo et al., 2016).

Recently, a cross-sectional study showed a dose-re-

sponse association between frequency of sexual harassment and pre-

valent depressive disorder among US and Canada based

ﬂight

atten-

dants (Gale

et al., 2019).

Longitudinally,

Nielsen and Einarsen (2012)

reported in a Norwe-

gian study, that women exposed to sexual harassment had a two-fold

higher risk of psychological distress, measured with the Hopkins

Symptoms Checklist-25 (HSCL-25) a screening instrument for common

psychiatric problems, including but not limited to depressive symptoms

(Nettelbladt

et al., 1993).

Thus, the outcome was broader and less

speciﬁc than the outcome in our study. Nielsen and Einarsen used a

more comprehensive assessment of sexual harassment than the present

study, applying the 11 item Bergen Sexual Harassment scale

(Nielsen

et al., 2010),

whereas our measurement of sexual harassment

was limited to a single item.

4.3. Strengths and limitations

Strengths of the study include the longitudinal design, the large

study population comprising a wide range of occupations in the Danish

workforce, and the measurement of depressive symptoms and disorder

with a clinically validated rating scale. To our knowledge, this is the

ﬁrst

cohort study demonstrating an association between onset of ex-

posure to workplace sexual harassment and subsequent risk of elevated

depressive symptoms and incident depressive disorder.

Several important limitations should be noted. First, we measured

sexual harassment with a single global item, which might have caused

an underestimation of the prevalence of sexual harassment. Using a

scale providing speciﬁc examples of sexual harassment e.g., about un-

wanted touching or verbal sexual suggestions, might have resulted in

the reporting of higher number of events of harassment, particularly of

events that may have been regarded by the study participants as less

severe (Nielsen

et al., 2010).

Second, we measured depressive disorder with the MDI, an instru-

ment that has previously been validated in clinical studies (Bech

et al.,

2001, 2015; Olsen et al., 2003).

The strong association between onset of

sexual harassment and a

ﬁve-fold

higher risk of incident depressive

disorder is an important result of this study, as it indicates that sexual

harassment not only aﬀects individuals’ well-being but may also con-

tribute to the development of a clinical disorder. However, caution is

needed in the interpretation of the result, as the gold standard measure

for assessing a depressive disorder in research studies is a clinical di-

agnostic interview, which was not available in this large population-

based study. The MDI is focused on the frequency and duration of

symptoms of clinical depression, but, unlike a clinical diagnostic in-

terview, does not assess impairment in diﬀerent areas of living.

Therefore, the results on incident depressive disorder need to be re-

plicated in further clinical studies.

Third, individuals who later experienced onset of sexual harassment

had already at baseline higher levels of depressive symptoms than in-

dividuals who later did not experience sexual harassment. As we ad-

justed all estimates for baseline depressive symptoms, our results were

not biased by this unexpected

ﬁnding.

However, as described in detail

above, further research on explanations for this

ﬁnding

is needed.

Fourth, as delineated in the section

“interpretation

of the results”,

we measured onset of exposure to sexual harassment during the last 12

months retrospectively in the 2014 (t2) survey and we cannot rule out

that elevated depressive symptoms in 2014 that had other reasons than

exposure to sexual harassment, may have led participants to over-

estimate the occurrence of harassment. We attempted to mitigate this

potential bias by adjusting for depressive symptoms in 2012 (t1).

Fifth, although we analyzed data of almost 10,000 individuals with

two measures (cohort I) and more than 6600 individuals with three

measures (cohort II), the study sample was still not large enough for

performing a number of desirable subgroup analyses, as both onset of

exposure to sexual harassment and incident depressive disorder was

rare. For example, we could not analyze whether the frequency of the

harassment or the status of the perpetrator within the group of work-

place personnel (colleague, supervisor or subordinate) were related to

the subsequent level of depressive symptoms and risk of depressive

disorder. When further waves of WEHD with more study participants

become available in the future, we may be able to perform some of

these subgroup analyses.

Sixth, because of the low number of individuals with onset of sexual

harassment, the results from the sex-stratiﬁed analyses need to be

viewed with caution. In these subgroup analyses, the exposure groups

were small, particularly among men, and although we did not

ﬁnd

evidence for that pattern of associations were diﬀerent for women and

for men, we cannot rule out that such diﬀerent patterns may have

emerged in a larger study sample.

5. Conclusion

Onset of workplace sexual harassment is associated with elevated

depressive symptoms and higher risk of incident depressive disorder in

the Danish workforce. A particularly strong association was found for

the association of onset of sexual harassment from workplace personal

and incident depressive disorder, with an odds ratio of more than

ﬁve.

Workplace sexual harassment may be a potential contributing factor in

the aetiology of depressive symptoms and disorder.

Declaration of Competing Interest

All authors declare no conﬂict of interest.

Funding

The study was supported by the Danish Working Environment

Research Fund (Grant no. 37-2014-09). The funding source had no in-

volvement in the study design, the data collection, the analysis, the

interpretation of data, the writing of the paper, or the decision to

submit the paper for publication.

R. Rugulies, et al.

Journal of Affective Disorders 277 (2020) 21–29

Gale, S., Mordukhovich, I., Newlan, S., McNeely, E., 2019. The impact of workplace

harassment on health in a working cohort. Front Psychol. 10, 1181.

Johnsen, N.F., Thomsen, B.L., Hansen, J.V., Christensen, B.S., Rugulies, R., Schlünssen,

V., 2019. Job type and other socio-demographic factors associated with participation

in a national, cross-sectional study of Danish employees. BMJ Open 9, e027056.

McDonald, P., 2012. Workplace sexual harassment 30 years on: a review of the literature.

Int. J. Manag. Rev. 14, 1–17.

Mendes, K., Ringrose, J., Keller, J., 2018. #MeToo and the promise and pitfalls of chal-

lenging rape culture through digital feminist activism. Eur. J. Women's Stud. 25,

236–246.

Nettelbladt, P., Hansson, L., Stefansson, C.G., Borgquist, L., Nordstrom, G., 1993. Test

characteristics of the Hopkins Symptom Check List-25 (HSCL-25) in Sweden, using

the Present State Examination (PSE-9) as a caseness criterion. Soc. Psychiatry

Psychiatr. Epidemiol. 28, 130–133.

Nielsen, M.B., Bjørkelo, B., Notelaers, G., Einarsen, S., 2010. Sexual harassment: pre-

valence, outcomes, and dender diﬀerences assessed by three diﬀerent estimation

methods. J. Aggress. Maltreat. Trauma 19, 252–274.

Nielsen, M.B., Einarsen, S., 2012. Prospective relationships between workplace sexual

harassment and psychological distress. Occup. Med. 62, 226–228.

Nielsen, M.B.D., Kjaer, S., Aldrich, P.T., Madsen, I.E.H., Friborg, M.K., Rugulies, R.,

Folker, A.P., 2017. Sexual harassment in care work - Dilemmas and consequences: a

qualitative investigation. Int. J. Nurs. Stud. 70, 122–130.

O'Neil, A., Sojo, V., Fileborn, B., Scovelle, A.J., Milner, A., 2018. The #MeToo movement:

an opportunity in public health? Lancet 391, 2587–2589.

Olsen, L.R., Jensen, D.V., Noerholm, V., Martiny, K., Bech, P., 2003. The internal and

external validity of the Major Depression Inventory in measuring severity of de-

pressive states. Psychol. Med. 33, 351–356.

Pedersen, C.B., 2011. The Danish Civil Registration System. Scand. J. Public Health 39,

22–25.

Quick, J.C., McFadyen, M.A., 2017. Sexual harassment: have we made any progress? J.

Occup. Health Psychol. 22, 286–298.

Sojo, V.E., Wood, R.E., Genat, A.E., 2016. Harmful workplace experiences and women's

occupational well-being: a meta-analysis. Psychol. Women Q. 40, 10–40.

Spector, P.E., Zhou, Z.E., Che, X.X., 2014. Nurse exposure to physical and nonphysical

violence, bullying, and sexual harassment: a quantitative review. Int. J. Nurs. Stud.

51, 72–84.

Torma, K., Simbold, C.T., Sørensen, A.G., Madsen, K.K., Skjelbo, K., 2007. Dansk

Branchekode 2007, DB07. Danish Industrial Classiﬁcation of All Economic Activities

2007. Revideret december 2015. Statistics Denmark, Copenhagen. Available from:

http://www.dst.dk/Site/Dst/Udgivelser/GetPubFile.aspx?id=11119&sid=helepubl

(retrieved 10 January 2020).

Willness, C.R., Steel, P., Lee, K., 2007. A meta-analysis of the antecedents and con-

sequences of workplace sexual harassment. Pers. Psychol. 60, 127–162.

Author Contributions

RR and IEHM conceived the study. RR, IEHM and KS designed the

analyses. KS conducted the data analysis and JKS assisted in conducting

the data analysis. All authors interpreted the data and discussed the

results. RR wrote the

ﬁrst

draft of the manuscript and all authors re-

vised the draft critically for important intellectual content. All authors

read and approved the

ﬁnal

version for submission.

Acknowledgment

None.

Supplementary materials

Supplementary material associated with this article can be found, in

the online version, at doi:10.1016/j.jad.2020.06.058.

References

Bech, P., Rasmussen, N.A., Olsen, L.R., Noerholm, V., Abildgaard, W., 2001. The sensi-

tivity and speciﬁcity of the Major Depression Inventory, using the Present State

Examination as the index of diagnostic validity. J. Aﬀect. Disord. 66, 159–164.

Bech, P., Timmerby, N., Martiny, K., Lunde, M., Soendergaard, S., 2015. Psychometric

evaluation of the Major Depression Inventory (MDI) as depression severity scale using

the LEAD (Longitudinal Expert Assessment of All Data) as index of validity. BMC

Psychiatry 15, 190.

Choo, E.K., Byington, C.L., Johnson, N.L., Jagsi, R., 2019. From #MeToo to #TimesUp in

health care: can a culture of accountability end inequity and harassment? Lancet 393,

499–502.

Freischlag, J.A., Faria, P., 2018. It is time for women (and men) to be brave: a con-

sequence of the #MeToo movement. JAMA 319, 1761–1762.

Friborg, M.K., Hansen, J.V., Aldrich, P.T., Folker, A.P., Kjaer, S., Nielsen, M.B.D.,

Rugulies, R., Madsen, I.E.H., 2017. Workplace sexual harassment and depressive

symptoms: a cross-sectional multilevel analysis comparing harassment from clients or

customers to harassment from other employees amongst 7603 Danish employees

from 1041 organizations. BMC Public Health 17, 675.