Beatriz Rayane Oliveira Santana1; Amanda Oliveira Barros1; Roberta Machado Pimentel Rebello de Matos1; Deborah Pimentel1,2
BACKGROUND: Health care workers are available to provide care to patients, but lack of concern with their lives, work organization and difficult interpersonal relationships make them susceptible to physical or mental diseases.
OBJECTIVE: To establish the profile of health care workers in the public sector in Sergipe, Brazil, granted sick leave due to depression, frequency of relapse and characteristics of absenteeism. Methods: Cross-sectional and descriptive study in which we analyzed secondary data for the period from 2009 2017 available in the State Secretariat of Planning, Budget and Management electronic records.
RESULTS: Sixty-three workers required sick leave, representing a total of 290 medical legal examinations. Workers who required sick leave were mostly female (90.5%), married (54.0%), had a master's degree (33.3%) and were nursing technicians (34.9%). The most frequent diagnosis as per the International Classification of Diseases (ICD-10) was single major depressive disorder (F32), 26.5%. The average number of recurrent spells was 3.6 per worker.
CONCLUSION: The prevalence of depression among the analyzed health care workers was high and thus represents a cause of concern requiring intervention.
Keywords: health personnel; absenteeism; depression.
INTRODUÇÃO: Os profissionais da saúde dispõem-se a zelar pela saúde dos seus pacientes, entretanto a escassez de preocupação com sua vida, além da forma organizacional do trabalho e as difíceis relações interpessoais, os torna susceptíveis ao adoecimento físico e/ou mental.
OBJETIVOS: Descrever o perfil do servidor público estadual das áreas da saúde com afastamento do trabalho por depressão em Sergipe, bem como avaliar o índice de reincidência e as características do afastamento.
MÉTODOS: Estudo descritivo, de corte transversal, com coleta dos dados secundários do arquivo eletrônico da Secretaria de Estado do Planejamento, Orçamento e Gestão (Seplag) dos anos 2009 a 2017.
RESULTADOS: No período entre 2009 e 2017, afastaram-se 63 profissionais da saúde, com o total de 290 atendimentos. O perfil do profissional absenteísta correspondeu ao sexo feminino (90,5%), casado (54,0%) e com mestrado (33,3%). A categoria que mais se afastou foi o técnico de enfermagem (34,9%). A Classificação Internacional de Doenças mais prevalente do total de atendimentos foi F32 (episódios depressivos), em 26,5% dos casos. Entre os que apresentaram recidivas, a média foi de 3,6.
CONCLUSÃO: Os resultados mostraram que a depressão em profissionais da saúde tem alta prevalência, com uma realidade preocupante e que necessita de intervenções.
Palavras-chave: profissionais da saúde; absenteísmo; depressão.
According to the World Health Organization (WHO), mental and behavioral disorders (MBD) account for 13% of all diseases and affect 700 million people worldwide1. While their incidence is increasing as a whole, that of depression stands out2.
Depression is a mood disorder defined as presence for at least two weeks of five or more of the following symptoms: depressed mood without any identifiable reason, loss of pleasure, fatigue, changes in appetite, body weight, sleep and activities, suicidal thoughts, cognitive and memory disorders and feelings of guilt3-5. This condition is associated with a personal dysfunction that might return cyclically or at definite times6.
This problem is categorized in the International Classification of Diseases (ICD-10) as major depressive disorder, single (F32) or recurrent (F33). In ICD-11-presented to WHO Member States in May 2019 to enter in force on 1 January 2022-it is described as single episode (6A70) or recurrent (6A71) depressive disorder7.
Hard work was considered in the eighteenth century the best treatment for depressed individuals, since sadness, discouragement and suicidal thoughts were believed to be caused by physical inactivity. This idea is now outdated given that work might actually have negative impacts on the life of workers2,8. Depressive disorders are associated with impaired productivity and may lead to incapacity for work as a result of accidents, physical or mental diseases6,9.
According to the WHO, Brazil is the leading country in frequency of depression, which affects 5.8% of the population1. Some estimates indicate that by 2020 depression will be the main global cause of disability10,11 MBD are the third leading cause of work incapacity in Brazil and account for 9% of sick-pay benefits and disability retirement12.
Rated the disease of the century, depression affects workers in any occupational group, more particularly those whose job involves helping others, namely, health care workers4. The aim of undergraduate education in their case is to make them learn how to work mechanically and objectively, with full neglect of the need to also provide psychological and professional support despite its relevance for the ideal of humane health care. The curricula also pass over the psychological preparation of professionals for hospital work that contributes to the prevention of illness among this population of workers6,13.
Workers and the physical environment at hospitals have unique characteristics13 derived from the demands to provide rapid and individualized care14. These characteristics might bear consequences for the lives of these professionals. To be sure, the impact of disease is not restricted to patients and their families, but also affects care providers6. The daily routine at hospitals is a source of stress and poses high mental and emotional demands to workers, which situation favors the occurrence of mental disorders6,13.
We may represent this situation as scales, with the organizational objectives and infrastructure on one side and professional integrity on the other. When unbalanced, this relationship might trigger stress and the workplace becomes a cause of anxiety or even depression. Their job daily exposes health care workers to this sort of imbalance. This population of workers is subjected to rotating three-shift schedules, which have serious biopsychosocial consequences and impair their quality of life13. Moreover, these workers have to cope with the responsibilities inherent to the care of human beings, in addition to conflict with patients, interpersonal relationships with coworkers and supervisors and risk of contamination6,10,13,14, all which circumstances are common causes of imbalance.
As a function of the aforementioned considerations, the aims of the present study were to establish the profile of health care workers at public institutions in Sergipe, Brazil, who required sick leave for depression in the period from 2009 through 2017 and to analyze relapse and the characteristics of sickness absenteeism.
In the present cross-sectional and descriptive study we analyzed secondary data retrieved from the electronic records of the State Secretariat of Planning, Budget and Management of Sergipe (Secretaria de Estado do Planejamento, Orçamento e Gestão - SEPLAG) relative to the medical records of employees subjected to medical legal examination to receive paid sick leave in the period from 2009 to 2017. The present study is part of the research project Profile of Health and Education Civil Servants Granted Sick Leave for Depression in Sergipe from 2009 through 2007, approved by the research ethics committee of Tiradentes University, ruling no. 3,048,551.
Our sample comprised 63 employees of the State Secretariat of Health, including nursing technicians and assistants, health agents, physicians, nurses, laboratory and health technicians and assistants, social counselors and psychologists. This group was granted a total of 290 sick leaves along the analyzed period.
We considered the following variables in analysis: age, sex, marital status, educational level, diagnosis as per ICD-10, severity, duration, outcome (leave, provisional or definitive readjustment) and length in the job. Diagnosis of depression was categorized in SEPLAG records as ICD-10 codes F32 and F33.
Since the present study involved documentary research only, there was no need to obtain informed consent and none of the analyzed workers was exposed to risk as per the criteria established in the Resolution no. 466/2012.
We included all health care workers seen at SEPLAG medical legal examination department and granted sick leave for depression along a 9-year period (2009 to 2017) to a total of 63 employees. We did not establish any exclusion criterion. The selected time interval began in 2009, i.e. the year when electronic medical records were first implemented at SEPLAG.
Data were retrieved from SEPLAG digital reports, were processed with software Microsoft Excel 2013 and subjected to statistical analysis with R Core Team 2018. Categorical variables are described as absolute and relative frequencies and continuous variables as mean, standard deviation, median, maximum and minimum.
There were 13,578 active health care workers in the Sergipe public health system in 2018. Overall, 189 of these employees were granted a first sick leave for any health problem, 63 for depression (33%) who were considered for analysis.
Fifty-three subjects were female (90.5%), the largest proportion was aged 40 to 49 years old, mean 50, minimum 35, maximum 70. A little more than half of the sample (54.0%) was married, and the largest proportion had completed higher education (33.3%) or earned a master's degree (33.3%) (Table 1).
Two subjects had two jobs, therefore, the total number of registered employee agreements was 65 instead of 63 (Table 1). Of the six physicians, three were specialists (one intensivist, one medical legal examiner and one radiation therapist).
The average length in the job for the analyzed sample was 20.5 years, ranging from 1 to 38.
The mean income of the analyzed workers was calculated from data retrieved from the Integrated System of Sergipe State Civil Servants available at the state government website (Table 2). As the results show, the highest mean salary corresponded to physicians and the lowest to laboratory assistants15.
The medical legal examination department analyzed 910 cases of mental disorders along the analyzed period. A total of 290 cases (31.8%) corresponded to ICD-10 codes F32 and F33, followed by anxiety disorder, bipolar disorder and mixed anxiety-depressive disorder.
A total of 290 sick leaves were granted for depression along the analyzed period, mean 32/year. Annual distribution in decreasing order was: 56 in 2010, 45 in 2013, 44 in 2011, 29 in 2009, 32 in 2012, 28 in 2015, 26 in 2014, 16 in 2016 and 14 in 2017 (Graphic 1).
Forty-eight workers (76.2%) visited the medical legal examination department more than once, to a total of 227 visits, being 3.6 visits per employee, on average. This group mainly comprised women (n=45, 93.8%), nursing assistants (n=18, 37.5%), married employees (n=52.1%) and cases attributed ICD-10 code F32. Paid sick leave for more than 15 days was the most frequent outcome of such visits (56%). This was also the most prevalent outcome for the sample as a whole, corresponding to more than 75% of the cases (Table 3).
ICD-10 code F32 was the most frequent diagnosis for the employees who required one or several leaves (Table 4). Similarly, it was also the most prevalent code attributed in all the examinations (26.5%), followed by F32.1-single, moderate major depressive episode (18.6%) (Table 5). The sample was granted 12,928 days off work in total, mean 205.2 days, minimum 5, maximum 771.
In the present study the highest prevalence of sick leave for depression corresponded to women (90.5%) which agrees with reports in the literature10,16. Some authors discussed reasons for this phenomenon. In our study, the highest rates of absenteeism corresponded to the nursing staff, in which women predominate all across Brazil16. Another possible reason derives from the overall situation of families, which might have also impact on the world of work10. For instance, motherhood, child care and difficulties to match the workers and their children's vacation schedules might be a cause of conflict and of role concerns10,17. Then, there are hormonal differences between the sexes. Premenstrual syndrome is one of such differences, inasmuch as women become more tense at a definite time in the month, eventually exhibiting mood changes which in extreme cases might manifest as irritability and even depression. As a result, stressors liable to trigger mental distress differ between the sexes17.
Sick leaves were mainly granted to workers aged 40 to 49 years old, mean 50, which disagrees from most reports in the literature10,16,18. One exception is the study by Lemos et al.17 performed in large hospital in the Federal District of Brazil, in which the largest proportion (30.2%) corresponded to workers aged 41 to 50, therefore, closer to our findings.
Workers in Sergipe who required sick leave for depression were overall older, therefore more mature, with higher educational level and longer time in the job (average: 20.5 years). The latter factor is a determinant of depression among health care workers. Indeed, the longer time in the job, the higher the rate of sickness absenteeism18. Then, one may assume that the workers with longer time in the job were also exposed to double burden-paid job and child care-since married employees represented 54% of the sample. Thus being, one may infer that this group was more tired and stressed that the younger employees. Most studies reported similar findings i.e. married workers represented the largest proportion17-19, except for that by Alves et al.16 in which mood disorders were more frequent among separated/divorced workers.
In several studies the average age of workers who required sick leave varied from 21 to 39 years old10,16,18. According to the authors of a study performed in Ireland, the odds of developing mood disorders are higher for the younger and less experienced workers, because the older and more experienced ones are better able to cope with their emotions and to perform their tasks according to their workload10,19.
In our study, nursing professionals were the group that most required sick leave for depression, representing 83% of the cases. The nursing staff-the main workforce in hospitals17,20-includes three occupational groups: nurses, nursing technicians and assistants. The tasks of the latter two have a more mechanical than intellectual nature, and in the present study 75% of these workers required sick leave for depression. The main difference between these two occupational groups and all others involving higher education depends on the degree of complexity of patient care tasks. Nursing technicians are fit to provide care to medium- and high-complexity patients, while nursing assistants rather tend to see low-complexity outpatients21. On these grounds, we might conclude that increasing complexity and higher workload might be associated with sickness absenteeism. Several studies showed that work overload is the most stressful factor for the nursing staff and other categories of health care workers19,22,23.
Our results relative to the educational level of the workers who most required sick leave disagree from the reports in the literature. In their study with the nursing staff of a private and a public hospital, Furlan and Stancato observed that the jobs which required secondary education only involved heavier physical effort, thus were associated with higher emotional loads and consequently higher prevalence of depression17,18. Differently, 65% of our sample had completed higher education/earned a master's degree, possibly in association with the greater responsibilities of higher-level workers, which demand considerable intellectual effort and cause stress and mental disorders24. Absenteeism is six times higher among nursing technicians and assistants compared to occupational groups with higher educational level2,18. In the present study, prevalence was about three times higher, therefore half of that reported by Furlan and Stancato.
As reported in the literature, also in our study nursing professionals were the group most predisposed to develop mental disorders. Depression, in particular, is one of the three leading disorders among this occupational group19,22. There is a consensus in the literature on that physicians, nursing professionals and community health agents are exposed to mental distress16,23. Yet, this condition is often passed over on clinical evaluation, because patients may underestimate their symptoms, examiners lack the required knowledge or these problems manifest as physical symptoms. This was also the case in the present study.
Upon falling ill, any individual, health care workers in particular, lose some degree of their delusory completeness, i.e. they suffer a wound to their sense of omnipotence23. This phenomenon occurs mainly among physicians, who are more resistant to acknowledge their limitations and do not seek the necessary help when in mental distress24.
Medical students, residents and specialists exhibit considerable rates of depressive symptoms, which might interfere with the care provided to patients and their own quality of life from the very onset of their career and all across their lives. Physicians are under continuous pressure and as a result, they become increasingly susceptible to mental disorders25. The prevalence of depressive symptoms among physicians varied from 10% to 15% in studies performed in the United States, Great Britain, Norway and Japan26, i.e. rates similar to the that found in the present study-10% of the workers who required sick leave were physicians.
One of the physicians in the analyzed sample worked at an intensive care unit. This type of facility is considered violent, a cause of anguish and shock, and thus might impair the state of health of professionals. Workplace violence is a significant predictor of mental disorders27. Workers exposed to workplace violence are four times more predisposed to depression, as shown in studies performed in Poland and Turkey26.
Work overload is a cause of job dissatisfaction and might give rise to mental distress and subsequent absenteeism17,19. In the case of health care workers, work overload results in poorer quality of care provision16,17.
Work schedule is a variable still controversial in the literature. While night shifts interfere with the sleep-wake cycle, depression has stronger association with daytime work, perhaps as a function of the tasks performed, as e.g. bathing, dressing wounds and other procedures. The division of labor in shifts often holds health care workers hostages to their job2,10.
Having more than one job increases the odds of physical and emotional exhaustion among health care workers and interferes with their social and family life. Yet, given their low salary, these workers often need a second job or to work double shifts2,10. Indeed, the results of the present study show that the lower the income, the higher the frequency of MBD, as also Alves et al.16 found in their study performed in Pernambuco, Brazil. In another study, 27.38% and 18.03% of the nursing staff in a private and a public hospital, respectively, reported to believe that salary influences absenteeism. The reason is that low salaries compel this population to have more than one jobs to meet their basic needs18.
In the present study, the highest absenteeism rate corresponded to the nursing technicians, who earn the equivalent to 2.5 times the minimum wage, on average. Similar findings were reported by Alves et al.16 In their study the frequency of MBD was twice higher among the workers who earned the equivalent to once or twice the minimum wage compared to those with salaries six times higher than the minimum wage.
Environmental stressors might act in two ways, one that favors depression and burnout, while the other might make relapse individuals who have already returned to work17,25,28. The latter aspect has paramount importance, because in the present study relapse occurred among 48 (76.2%) workers, 3.6 spells on average, which shows that a stressful workplaces might make mental exhaustion become chronic.
Brazil exhibits one of the highest global prevalence rates of depression: 18.4% of the population has already experienced a depressive episode in life. Only in France (21.0%) and the United States (19.2%) this proportion is higher. Then, the prevalence of depressive symptoms and suicide is very high among health care workers2,19.
Sick leave amounts to absenteeism when they last longer than 3 days. Leaves are ratedshort when they last up to 15 days and long when they last longer2. In the present study, long leaves were more frequent, corresponding to 78% of the cases. In the study by Lemos et al.17 most health care workers in public institutions in the Federal District, Brazil, required 18-day sick leaves, on average. In the present study, the average length of spells was 205.2 days, varying from 5 to 771.
The limitations of the present study derive from the fact we only analyzed secondary data, therefore other factors could not be considered. Then, the literature on sick leaves granted to health care workers after medical legal examination is still scarce, which fact hindered comparisons and a more thorough discussion. This situation calls for additional studies, as was also observed by Fontinhas and Cardoso13, Silva et al.19 and Fernandes et al.23.
To conclude, the profile of sick-leave spells for depression among health care workers corresponds to nursing technicians, female workers, age 50 years old, being married, having attended higher education or earned a master’s degrees, 3.6 relapses on average and mean duration 205.2 days. These results point to the need to pay particular attention to health care workers, since they work in a stressful and tiring environment liable to cause depressive disorders. Depression can be prevented provided its origin is accurately identified by both workers and managers. In addition, strategies should be formulated to minimize psychological distress in the workplace through a well-balanced division of tasks to reduce work overload and promote good coworker relationships with the support from managers. The current challenge to managers is how to develop a healthy working environment fit to meet individual and collective demands, with the infrastructure needed for workers to do their job. Familiarity with triggers is a good point of departure to plan interventions to improve the working environment and the quality of life of workers, and thus reduce absenteeism and improve the quality of service delivery. Within this context, programs centered on the mental health of health care workers have paramount importance, including psychologists and psychiatrists to provide preventive care.
We thank the National Council of Scientific and Technological Development (CNPq) for the undergraduate research scholarship grant.
1. World Health Organization. Depression and Other Common Mental Disorders: Global Health Estimates [Internet]. Genebra: WHO; 2017 [acessado em 21 nov. 2017]. Disponível em: http://apps.who.int/iris/bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf?ua=1
2. Costa FM, Vieira MA, Sena RR. Absenteísmo relacionado a doenças entre membros da equipe de enfermagem de um hospital escola. Reben. 2009;62(1):38-44. http://dx.doi.org/10.1590/S0034-71672009000100006
3. American Psychiatric Association. Manual Diagnóstico e Estatístico de Transtornos Mentais - DSM-5. 5ª ed. São Paulo: Artmed; 2014.
4. Sadock BJ, Sadock VA, Ruiz P. Compêndio de Psiquiatria. Ciência do Comportamento e Psiquiatria Clínica. 9ª ed. São Paulo: Artmed; 2017.
5. Jardim S. Depressão e trabalho: ruptura de laço social. Rev Bras Saúde Ocup. 2011;36(123):84-92. http://dx.doi.org/10.1590/S0303-76572011000100008
6. Gomes RSM, Alencar CT, Wallau I, Castro UR. Transtornos depressivos em profissionais de saúde. Rev Med Saúde Brasília. 2015;4(1):122-8.
7. World Health Organization. International Classification of Diseases [Internet]. Genebra: WHO, 2017 [acessado em 26 out. 2018]. Disponível em: http://www.who.int/classifications/icd/en/
8. Cunha FO, Brito MFSF, Borém LMA, Messias RB, Leite MTS, Neto JFR. Qualidade de vida de médicos da atenção primária à saúde e dos serviços de urgência e emergência. Renome. 2016;5(2):52-62.
9. Bernburg M, Vitzthum K, Groneberg DA, Mache S. Physicians' occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in German hospitals. BMJ Open. 2016;6:e011369. http://doi.org/10.1136/bmjopen-2016-011369
10. Santana LL, Sarquis LMM, Brey C, Miranda FMA, Felli VEA. Absenteísmo por transtornos mentais em trabalhadores de saúde em um hospital no sul do Brasil. Rev Gaúcha Enferm. 2016;37(1):e53485. http://dx.doi.org/10.1590/1983-1447.2016.01. 53485
11. Bastos MLA, Bezerra Júnior G, Domingos ET, Araújo RM, Santos AL. Afastamentos do trabalho por transtornos mentais: um estudo de caso com servidores públicos em uma instituição de ensino no Ceará, Brasil. Rev Bras Med Trab. 2018;16(1):53-9. http://doi.org/10.5327/Z1679443520180167
12. Fernandes MA, Silva DRA, Ibiapina ARS, Silva JS. Adoecimento mental e as relações com o trabalho: estudo com trabalhadores portadores de transtorno mental. Rev Bras Med Trab. 2018;16(3):277-86. http://doi.org/10.5327/Z1679443520180110
13. Fontinhas JE, Cardoso JMM. O estresse no trabalho do enfermeiro. Rev Uningá. 2016;51(1):78-86.
14. Pedro DRC, Silva GK, Lopes AP, Oliveira JL, Tonini NS. Violência ocupacional na equipe de enfermagem: análise à luz do conhecimento produzido. Saúde Debate. 2017;41(13):618-29. http://dx.doi.org/10.1590/0103-1104201711321
15. Governo de Sergipe. Portal da Transparência [Internet]. Sergipe; 2019 [acessado em jul. 2019]. Disponível em: http://www.transparenciasergipe.se.gov.br/TRS/Despesas/Favorecidos.xhtml
16. Alves AP, Pedrosa LA, Coimbra MA, Miranzi MA, Hass VJ. Prevalência de transtornos mentais comuns entre profissionais de saúde. Rev Enferm UERJ. 2015;23(1):64-9. http://dx.doi.org/10.12957/reuerj.2015.8150
17. Lemos DS, Escalda PM, Paz LP, Leão AL. Absenteísmo - doença entre servidores públicos do setor saúde do Distrito Federal. Rev Bras Med Trab. 2018;16(3):336-45. http://dx.doi.org/10.5327/Z1679443520180246
18. Furlan JAS, Stancato K. Fatores geradores do absenteísmo dos profissionais de enfermagem de um hospital público e um privado. RAS. 2013;15(60):112-20.
19. Silva DSD, Tavares NVS, Alexandre AR, Freitas DA, Brêda MZ, de Albuquerque MCS, et al. Depressão e risco de suicídio entre profissionais de Enfermagem: revisão integrativa. Rev Esc Enferm USP. 2015;49(6):1027-36. http://dx.doi.org/10.1590/S0080-623420150000600020
20. Perry L, Lamont S, Brunero S, Gallagher R, Duffield C. The mental health of nurses in acute teaching hospital settings: A cross-sectional survey. BMC Nurs. 2015;14:15. https://doi.org/10.1186/s12912-015-0068-8
21. Univeritas. Saiba a diferença entre enfermeiro, técnico e auxiliar [Internet]. Univeritas; 2017 [acessado em 9 fev. 2017]. Disponível em: https://www.univeritas.com/noticias/saiba-diferenca-entre-enfermeiro-tecnico-e-auxiliar
22. Vieira TG, Beck CLC, Dissen CM, Camponogara S, Gobatto M, Coelho APF. Adoecimento e uso de medicamentos psicoativos entre trabalhadores de enfermagem de unidades de terapia intensiva. REUFSM. 2013;3(2):205-14. http://dx.doi.org/10.5902/217976927538
23. Fernandes MA, Soares LM, Silva JS. Transtornos mentais associados ao trabalho em profissionais de enfermagem: uma revisão integrativa brasileira. Rev Bras Med Trab. 2018;16(2):218-24.
24. Pimentel D. O sonho do jaleco branco: saúde mental dos profissionais da saúde. Aracaju: Universidade Federal de Sergipe/Fundação Oviêdo Teixeira/Sociedade Médica de Sergipe; 2005.
25. Silveira AL, Colleta TC, Ono HR, Woitas LR, Soares SH, Andrade VL, et al. Síndrome de Burnout: consequências e implicações de uma realidade cada vez mais prevalente na vida dos profissionais de saúde. Rev Bras Med Trab. 2016;14(3):275-84. http://dx.doi.org/10.5327/Z1679-443520163215
26. Gong Y, Han T, Chen W, Dib HH, Yang G, Zhuang R, et al. Prevalence of Anxiety and Depressive Symptoms and Related Risk Factors among Physicians in China: A Cross- Sectional Study. PLoS One. 2014;9(7):e103242. https://doi.org/10.1371/journal.pone.0103242
27. Peixoto OS, Pereira IV. Assédio moral no trabalho: repercussões sobre a saúde do trabalhador. Rev Bras Med Trab. 2005;3(2):135-7. http://dx.doi.org/10.1590/2317-6369000015918
28. Corbière M, Renard M, St-Arnaud L, Coutu MF, Negrini A, Suavé G, et al. Union perceptions of factors related to the return to work of employees with depression. J Occup Rehabil. 2015;25(2):335-47. https://doi.org/10.1007/s10926-014-9542-5
7 de Maio de 2019.
Aceito em 3 de Setembro de 2019.
Fonte de financiamento: Conselho Nacional de Desenvolvimento Científico e Tecnológico