Predictors of psychopathologic symptoms by work-related stress factors in Mental Health Professionals of a tertiary-level Psychiatric Hospital in Mexico City

Introduction: Mexico has a high prevalence of work stress; mental health professionals are a vulnerable group who experience demanding environments that place their own mental health at risk. Objective: The present study aimed to evaluate the work-related stress levels and development of psychopathology in mental health professionals of a tertiary-level psychiatric hospital in Mexico City. Methods: The study included 90 mental health professionals, utilizing two questionnaires: (1) to analyze the level of occupational stress, the Stress Work Instrument (SWI) for Mexican physicians was employed; and (2) for symptomatic distress, the Symptom Checklist-90-Revised (SCL-90-R) was applied. Two theoretical assumptions’ (‘Effort-Reward’ for Karasek and “Effort-Reward Imbalance” for Siegrist) were used to propose an analytical model based on structural equations. Results: The model obtained showed a high and positive structural coe ﬃ cient (0.76). The goodness-of-ﬁ t for the model was acceptable ( χ 2 = 51.22, p = .02; CFI = .97; RMSEA = 0.08). This study showed a causal explanation for the generation of distress, and the model detected a strong and signi ﬁ cant effect from work stress to distress.


Introduction
Work-related stress is a global issue, recognized worldwide as a major problem facing healthcare professionals [1,2].Stress is an integral part of an employee's life, occurring due to a wide variety of job circumstances [3].However, stress can be short-term and positive (eustress), or long-term and negative stress (distress) [4].Both can lead to a variety of symptoms; however, long-term excessive stress can lead to psychological problems such as depression and anxiety [5].Research has consistently documented elevated rates of psychological stress in health professionals, particularly in emergency, intensive care, and psychiatry units [6][7][8].Psychological stress is defi ned as a particular relationship between the individual and their environment, that they themself evaluate as threatening or overwhelming with respect to their resources and jeopardizing their well-being [9].Work stress has been identifi ed as a group of emotional, psychological, cognitive, and behavioral reactions to professional demands that exceed workers' knowledge and abilities to perform optimally [5].Mexico has a high prevalence of work stress, ranking fi rst in the world [10].In the medical fi eld, mental health professionals are no exception.Those working in physically (heavy workload, long hours, job insecurity) and socially exhausting environments (from patients with mood disorders to violent, self-injurious, and suicidal patients) are at a high risk of developing psychopathology (anxiety and depression) [11].Various studies have reported that mental health professionals (psychiatric physicians, psychiatric trainees, and nursing personnel) exhibit burnout, job dissatisfaction, musculoskeletal disorders, absenteeism, and reduced effi ciency and performance in their organizations [12][13][14][15].In this respect, organizational culture has been known to be an important characteristic that infl uences the behaviors of groups and individuals within an organization, as in the case of public health hospitals.
These institutions are obliged to provide timely, acceptable, affordable, and satisfactory quality medical care.However, the effectiveness of the response depends on the organization of health services, mainly human and fi nancial resources.In this sense, Siegrist (1996) establishes in his effort-reward imbalance theory that a high-level effort in work and low rewards can lead to stress levels that affect the physical and mental health of workers [16,17].Various risk factors, such as low salary, work overload, inadequate working conditions, continuing educational training, etc., have been addressed as distress triggers.Moreover, theoretical assumptions by Karasek´s (1979) job demands-control establishes the key idea that control buffers the impact of job demands on the strain and can help enhance employees 'job satisfaction'.In this regard, lack of motivation and professional demerit are aspects related to low control and job dissatisfaction.This set of factors can induce emotional exhaustion that will impact the physical and mental health of workers.
Psychiatric trainees are exposed to excessive academic workloads, competition with peers, fear of failing, etc., and confl icts with work-life balance and hospital ward rotations [18].In addition, their subordinate status restricts their autonomy to different scales of decision-making [19].In Mexico, a study of physicians' trainees in a tertiary-level mental hospital in Mexico City identifi ed emotional burnout, excessive work demands, decreased motivation to perform tasks, demerited professional perceptions, and dissatisfaction with conditions provided by institutions [20].Regarding the risk of psychopathology, trainees exhibited depression and anxiety symptoms, suicidal ideation, and substance use [21].
Moreover, psychiatric nursing is one of the three most stressful professions.Among the stressful events that psychiatric nurses experience are aggressive patients, verbal and physical violence, recurrent relapses by poor adherence to treatment, etc. [21,22].Studies have demonstrated high levels of stress in psychiatric nurses, presenting with depressive and anxiety symptoms in several countries, including Mexico [22,23].
Moreover, psychiatrists have stressful work with intense emotions and feelings (fear, frustration, sense of failure, etc.) in their clinical practice [13].This group of professionals represents a high-risk group due to experiencing burnout, suicide risk, and alcohol and drug use, in addition to fulfi lling administrative duties, and may be unaccustomed to working in a constantly changing work environment, with high workload and work pace (working under time pressures), with strict or infl exible schedules, etc., predisposes psychiatrists to high levels of occupational stress [24].In such a way, work-related stress is a result of the mismatch between an individual and the environment, because of the harmful and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker [5].
Generally, a higher discrepancy between external stresses and an individual's capabilities causes a higher level of stress experienced [25].The suggested theoretical frameworks will support the concept that work-related stress is linked to negative mental health.The theoretical assumptions' of Karasek's "demand-control", or job strain, have been very important in research on the psychosocial work environment [26], stress, and illness since the early 1980s, describing and analyzing work situations in which stressors are chronic, and emphasizing the psychosocial characteristics of the work environment [26].The health variables have the greatest association and scientifi c evidence to mental health disorders [27].This evidence confi rms mental impairment in the face of synergy with high demands and under control at work [28,29].

Conclusion:
We conclude that the model obtained predicts a signifi cant effect of work-related stress on mental health such as anxiety, depression, somatization, and feelings of inadequacy in mental health professionals.Therefore, work-related stress factors should be minimized thus preventing distress to ensure that psychiatric personnel enjoy physical and mental health enabling them for effi cient and professional clinical practice.On the other hand, Siegrist related and complemented it with the theoretical assumption of "Effort-Reward Imbalance" (ERI), where he mentions that the interaction between a high effort and a low level of reward in the long term represents the situation posing the greatest risk to health [30].Based on the theoretical antecedents mentioned by the Karasek's "Demand-control" and Siegrist's "Effort-Reward Imbalance", the aim of this study was to evaluate the

Study location
The study was conducted with mental health workers at a tertiary-level mental hospital in Mexico City.A cross-sectional survey recruited participants from September 2014 to March 2015.

Sample and procedures
An observational, cross-sectional, prospective, and descriptive study was carried out, employing a questionnaire addressed to healthcare personnel (psychiatric physicians, psychiatric residents, and nursing personnel).The questionnaires contained an informed consent form, specifying that the survey was anonymous, and confi dentiality of information was assured.Two validated questionnaires were used: (1) the Stress Work Instrument (SWI) for Mexican physicians [31], to analyze the level of occupational stress; and (2) the Symptom Checklist-90-Revised (SCL90-R) [32], to assess symptomatic distress.The participants received suffi cient explanation about the study, and those who agreed to it were included in the analysis.
The procedure consisted of giving the questionnaire package to the participants, who answered and returned it that same day to be registered in the database for analysis.

Inclusion and exclusion criteria
Psychiatric physicians, psychiatric trainees, and nurses (male and female) working at tertiary-level mental hospitals in Mexico City, Mexico, were included in the study (INPRF-CEI C/059), which was approved by an institutional review board and a qualifi ed ethics review committee.All participants accepted and signed the informed consent form.Psychiatric trainees in rotation and health professionals who incompletely answered questionnaires or withdrew their informed consent were excluded.

Statistical analysis
For descriptive analysis, Pearson's correlation was performed using SPSS 22.0 (SPSS Inc, Chicago, IL, USA).Descriptive analysis was generated from the demographic characteristics to describe the participant's age, education, and religious beliefs.Pearson's correlations were conducted to examine the correlations between SCL-90-R factors (somatization, interpersonal sensitivity, depression, and anxiety) and Stress Work Instrument factors (emotional exhaustion, dissatisfaction with salary, dissatisfaction with professional practice, lack of motivation, work overload, and professional demerit).The signifi cance level was p<0.05.A structural equation model was specifi ed using EQS 6 [33], with maximum likelihood estimation (MLE).

Recruitment and characteristics of the sample
A total of 100 participants were initially selected, of which, 10 were subsequently excluded because they did not complete the questionnaire package.As a result, a total of 90 mental health professionals were enrolled, grouped as follows: psychiatric physicians (n = 28), psychiatric trainees (n = 33), and nursing personnel (n = 29).

Demographic data
The demographic characteristics of the groups are presented in Table 1.In this study, 90 mental health professionals (female n = 52, male n = 38) participated at the request of researchers through informed consent.As presented in Table 1, the data indicated that the average age was 36 years, and psychiatric residents were the youngest at 28 years.In the case of education, the average was 21 years, with nursing personnel exhibiting the fewest years of education at 17 years.In terms of religious beliefs, 71% and 29% were with and without religion, respectively; of those holding religious beliefs, 42% were nursing personnel.

Structural model with Maximum Likelihood Estimation (MLE)
To test the hypotheses, Structural Equation Analysis (SEM) was used to determine the direct and indirect effects of several latent and observed variables measured at the same time.A latent variable is one that uses other observed variables to measure the attribute.The SEM is used to estimate the association between the variables.Among the advantages of using this methodology are the simultaneous testing of direct, indirect, and total relationships between variables, the inclusion of measurement errors, and the correlation between variables and their measurement errors.
Based on structural modeling, we used the method of Maximum Likelihood (ML) to estimate the parameters.The model tested consists of two latent variables: the fi rst one, called Work Stress, and was made up of one of six observed variables, each one with high positive factor loadings, i.e., emotional exhaustion (0.95), dissatisfaction with salary (0.82), dissatisfaction with professional practice (0.91), lack of motivation (0.81), work overload (0.87), and professional demerit (0.81); the second latent variable called Distress and was made up of four observed variables, each one with high positive factor loading, i.e., somatization (0.78), interpersonal sensitivity (0.84), depression (0.83), and anxiety (0.81).
To estimate the effect size of the infl uence of Work Stress on Distress, structural modeling was used with the maximum likelihood method (ML) to estimate the parameters.The model obtained showed a high and positive structural coeffi cient (0.76).Considering as optimal indices, comparative fi t index (CFI) close to 1 and root mean square of approximation (RMSEA) less than 0.05, the goodness of fi t for the model was good (χ 2 = 51.22,p = 0.02; CFI = 0.97; RMSEA = 0.08) as seen in Figure 1, which indicates a plausible and congruent model that represents the potential relationship of two theoretical and proved constructors based on this solid and signifi cant structure.
Thus, we test and accept hypothesis 1, that is, there is a positive and direct infl uence between work stress and distress experienced by mental health professionals of a tertiary-level psychiatric hospital.Although the χ 2 index yielded signifi cant results, indicating differences between the saturated and the restricted model, this test is known to be sensitive to sample size; therefore, the literature suggests using the resulting χ 2 coeffi cient between its degrees of freedom, which must be at least three to indicate a good fi t [34] which, in this case, was 51.22/32 = 1.70.

Discussion
The prevention of physical and mental illness in workers should be a global priority [5].The purpose of this study was to ascertain the effect of developing psychopathology among mental health professionals on their work-related stress levels.For building the model concerning latent variable work stress, emotional exhaustion, as the observed variable, had the highest load (0.95).Various studies have shown that mental health professionals have poorer well-being than those in other health care units [2,35].Studies, particularly in Mexican cities, have shown that health professionals present average emotional exhaustion symptom values (burnout) [36].Mental health services in Mexico are limited, and it has been estimated that there are 0.67 psychiatric per 100,000 inhabitants.
Additionally, psychiatric care is concentrated in only three cities, one of which is Mexico City, and approximately 50% of patients with mental illness are treated in tertiary-level hospitals, which increases the workload [37]; not surprisingly, we observed high levels of work overload (0.87), in addition to emotional exhaustion.
Work takes up a signifi cant percentage of one's life; if the workload increases, workers expect fair payment.When these expectations are not met, it brings feelings of disappointment, bitterness, and lack of interest, leading to work dissatisfaction [38].Healthcare specialists in Mexico have an average salary of USD 1050, compared to USD 3400 dollars in the United States, which explains the salary and work dissatisfaction [39].One cause of work dissatisfaction is the lack of motivation; in our model, we noted high loads of the observed variable (0.81).
Motivation can be defi ned as a psychological process that gives behavior purpose and direction, which will impact the interactions between individuals and their work environment [40].However, motivational processes can be affected by determinants of motivation (such as salary, incentives, values, expectations, and poor work environment) affecting performance and work satisfaction, for example, in mental health professionals [41].Studies of health workers in Mexico showed low motivation, job dissatisfaction, and professional dissatisfaction rates of approximately 30% in a sample of fi ve thousand workers [42].In our study, we also found signifi cant levels of dissatisfaction with professional practices (0.91).This factor is a negative response or rejection and will depend, to a great extent, on the working conditions and personality of each person [43].Regarding working conditions, mental health professionals are exposed to stressors from outside the doctorpatient dynamic (increasingly litigious, increasing bureaucratic requirements, continuous academic updating, limited recourses, constantly changing work environment, etc.), which induce high levels of stress and thereby practicing professionals can develop emotional exhaustion and dissatisfaction [7].
Concerning personality, it has been observed that a fi vefactor model of personality (constituting traits of extraversion, neuroticism, openness to experience, agreeableness, and conscientiousness) is useful because its dimensions are related to different work or vocational dimensions [44].Additionally, job strain was positively predicted by neuroticism, and negatively by openness to experience and conscientiousness [45].Individuals with neuroticism respond poorly to environmental stress because they perceive their environment as distressing, threatening, and unsafe [46].In this regard, studies on psychiatrists and psychiatric trainees on personality revealed signifi cantly higher scores on neuroticism and lower scores on frustration tolerance [47].In addition, when comparing psychiatrists with physicians and surgeons, psychiatrists scored higher on items of neuroticism, openness, and agreeableness, but lower on conscientiousness [48].
A negative working environment can lead to physical and mental diseases [1].Studies in psychiatric hospitals have reported that psychiatrists, psychiatry trainees, and psychiatric nurses have a highly stressful occupation [7].Of the three groups, the psychiatry trainees' group is the most vulnerable, showing a high prevalence of anxiety disorders [20].Psychiatrists and psychiatric nurses exhibited a prevalence of depression, burnout, and anxiety [49].Moreover, we found high-load mental problems in the observed variables of depression (0.83), anxiety (0.81), somatization (0.78), and interpersonal sensitivity (0.84).As already mentioned, mental health professionals are exposed to high levels of stress with special characteristics in their area [11].Lazarus and Folkman developed a transactional model that proposes a defi nition of stress centered on the interaction between the individual and their environment [50].To this end, an evaluation of the organism is carried out in two parallel directions: one towards the environment, and the other towards one's own resources [50].Stress (distress) occurs when the person values their resources as scarce and insuffi cient to cope with environmental demands.In accordance with the above, there is perhaps a personal sensitivity that leads to the perception of stressors in a certain way, resulting in interpersonal site relationships (which could be related to interpersonal sensitivity variables of SCL-90) [32].Moreover, somatization is a conversion of the mental state into physical symptoms, meaning that all emotions have a physical component, in the absence of a known medical condition.Various studies have reported that psychosomatic symptoms can be related to multiple factors, including stress, depression, anxiety, and personality disorders [51].If workrelated stress reaches a state of distress, depression, anxiety, somatization, and interpersonal sensitivity can be developed, as shown in our results.
The central idea of this study was based on the antecedents mentioned by the Karasek's "Demand-control" and Siegrist's "Effort-Reward Imbalance" [26,30], served as the basis for proposing an analytical model; one way was to use the structural equations approach.This model consists of parameterizing the subjectivities by operationalizing the constructs (latent variables) through the observed variables measured through the psychometric instruments [52].From the results obtained, we can confi rm how all the estimated loads of the observed variables were high and positive with their respective latent variables.With the analytical and adjusted model of the structural equation, we explored causal explanations for the generation of distress and identifi ed a strong and signifi cant effect from Stress to Distress in the model.
The model obtained also confi rmed the infl uence of the variables that constitute stress due to work issues based on the theoretical assumptions' Karasek "Demand-control", i.e., the psychological demand that the perceived workload represents for the individual, including the amount of work, the pressure, and the time limits; in our study, these were measured through observed variables such as: (a) emotional exhaustion, referred to as those conditions that affect the individual and leave them exhausted at the end of a day, because they generate tension due to the responsibility for the task or for the fatigue that the workload represents; (b) lack of satisfaction of the professional practice under the conditions provided by the institution; (c) lack of motivation in fi nding the time to provide quality care, and even creating frustration regarding the possible expectations of professional growth; (d) work overload or feeling overwhelmed by the amount and effort that the activities involve; and (e) the referred aspects of professional demerit or not feeling valued in their performance, or believing that the recognition is not satisfactory.

Limitations
The fi ndings of this study should be interpreted with caution because it only investigates mental health professionals from one hospital in Mexico City, in this way the total sample size was 100 participants, which could have been a limitation because the results are not representative of the entire Mexico City mental health professional's workforce.Another limitation of our study is that we collected data from physicians and nurses working in Mexico, the extent to which our data can be transferred to other countries are unclear because the results refl ect the specifi c work environment of health mental hospital.

Conclusion
We conclude that the model obtained allows know the predictors in labor and organizational matters that can induce emotional exhaustion and lead to psychopathology development.In this sense, the work context of mental health professionals requires early interventions to care for the mental health of these workers.
The interventions could provide infographics (red fl ags), checklists, or short and preferably graphic materials (that promote interest and easy attention) for self-care of mental health; as well as to encourage the use of restorative spaces, preferably with access to nature, that allow them to relax, establish links with their peers and develop social cohesion.In addition the promotion by the institution a) the recognition of work performance, b) the development of policies that provide spaces for the evaluation of the mental health of mental health providers, c) the detection of risks or cases at risk of emotional exhaustion that require professional support, d) therapeutic alternatives that can provide opportunities to get away from the situation that generates distress temporarily.
effects of work-related stress levels on the development of psychopathology in mental health professionals at a tertiarylevel psychiatric hospital in Mexico City, and two hypotheses were proposed for testing: H1: Work-related stress has a positive effect on the development of distress.H2: Work-related stress has a negative effect on the development of distress.
Stress Work Instrument is an instrument consisting of 38 items with a Likert answer scale with four options: 0 (never) to 3 (frequently), where 0 indicates an innocuous situation, and 3 indicates a highly stressful situation, covering six valid factors: (1) emotional exhaustion; (2) dissatisfaction with salary; 3) dissatisfaction with professional practice; (4) lack of motivation; (5) work overload; and (6) professional demerit.It has an alpha value of 0.94 and explained variance of 56%.The Symptom Checklist-90-Revised (SCL-90-R) consists of 90 question items in nine subcategories: somatization, obsessivecompulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.The test respondents were instructed to select the corresponding scores depending on the prevalence of symptoms over the last seven days, including the day of the test, using a Likert scale of 0 (never) to 5 (very often).The mean reliability of each factor was estimated to have a Cronbach's alpha value of 0.81.Clinical measures of sociodemographic information, such as age, sex, education level, marital status, religion, and profession level were collected.The sample included 28 psychiatric physicians, 33 psychiatric trainees, and 29 nurses.

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Hernández Gutiérrez ME, Ortega-Andeane P, Mendieta D, García-Mejorado KV, Coballase-Urrutia E, et al. (2023) Predictors of psychopathologic symptoms by work-related stress factors in Mental Health Professionals of a tertiary-level Psychiatric Hospital in Mexico City.Arch Depress Anxiety 9(2): 060-067.DOI: https://dx.doi.org/10.17352/2455-5460.000082Pearson'scorrelation between Symptom Checklist-90-Revised (SCL-90-R) and Stress Work Instrument (SWI) factorsThe data in Table2 presentsthe correlations between the four factors of SCL90R and six factors of SWI, showing that all signifi cant associations (p ≤ 0.05) were positive.The relationships between the factors from SCL-90-R and SWI were moderate (ranging from 0.395 to 0.673), whereas as expected, the relationships were moderately high among the factors of SWI (ranging from 0.665 to 0.874) because they were part of the same instrument, as well as among the factors of SCL-90-R (ranging from 0.624 to 0.709).The moderate correlations between the factors of the two instruments are shown, in order to demonstrate that are moderate and therefore measure different constructs, i.e., one measures work stress and the other, aspects of psychopathology.As well as to avoid any multicollinearity issues, and also in order to meet the requirements for the development of the structural equation model.

Figure 1 :
Figure 1: Model of the infl uence of work stress on distress.

Table 1 :
Demographic characteristics of the groups.

Table 2 :
Product-moment correlation coeffi cients between the scores of the factors from SCL90-R and SWI.
**The correlation is signifi cant at the 0.01 level.