Distúrbios psíquicos menores e o contexto de trabalho da Polícia Civil: um estudo de método misto

J Bras Psiquiatr jbpsiq Jornal Brasileiro de Psiquiatria J. bras. psiquiatr. 0047-2085 1982-0208 Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro RESUMO Objetivo: Analisar a associação entre o contexto de trabalho e a presença de Distúrbios Psíquicos Menores (DPM) em Policiais Civis de Porto Alegre, Brasil. Métodos: Estudo misto, sequencial e exploratório. A amostra foi de 237 policiais para a etapa quantitativa e de 20 para a etapa qualitativa. O instrumento de pesquisa continha dados gerais do trabalhador e do estilo de vida, informações laborais e o Self-Reporting Questionnaire-20. Na etapa qualitativa, foram realizadas entrevistas semiestruturadas e análise temática. Para os dados quantitativos, utilizou-se estatística descritiva e inferencial. Resultados: A prevalência de distúrbios psiquiátricos menores foi de 26,2% (n = 62). As variáveis ritmo de trabalho acelerado (RP = 1,535; IC95% = 0,911-2,605), tratamento de saúde (RP = 1,752; IC95% = 0,987-3,010) e tratamento psicológico (RP = 2,704; IC95% = 1,604-4,516) associaram-se a maior prevalência de DPM. Os policiais com maior motivação no trabalho (RP = 0,721; IC95% = 0,579-0,897), mais de oito horas de sono por dia (RP = 0,747; IC95% = 0,574-0,971), alimentação saudável (RP = 0,545; IC95% = 0,320-0,946) e com filhos (RP = 0,731; IC95% = 0,523-0,986) associaram-se a menor prevalência de DPM. Na etapa qualitativa, emergiram duas categorias e quatro subcategorias relacionadas ao contexto de trabalho e às mudanças psiquiátricas nos policiais: “Contexto de trabalho da Polícia Civil” e “Trabalho e mudanças psiquiátricas”. Conclusão: Evidenciou-se a alta prevalência de DPM, bem como sua associação com o contexto de trabalho. INTRODUCTION The Brazilian Civil Police has the competence of ensuring compliance with the law and to investigate crimes against people and property. Thus, the civil police officers face a high risk of exposure to potentially fatal and traumatic events in their work environments1. Factors such as precarious working conditions and the current Brazilian scenario result in increasing demands to offer more efficient and effective responses in the control of violence and crime2. In addition, the high prevalence of urban violence, homicides, deaths from violence3, and the increase in the number of deaths of police officers on duty in recent years4 demonstrate the vulnerability of these workers. Data presented in the Atlas of Violence of the Institute for Applied Economic Research (IPEA) show that the state of Rio Grande do Sul has not had a significant change in homicide rates in the last 10 years. The city of Porto Alegre has an average rate higher than the state rate, with 24.5 homicides/100,000 inhabitants. Factors such as the high number of inhabitants, the high unemployment rate and the low investment in public safety also contribute to the sociodemographic context3,5,6. However, the work organization and the working conditions are often more stressful than the exposure to risk imposed by the profession, not being the work itself that provokes illnesses, but the way it is organized and the conditions to perform it7. The organization of the Civil Police work processes can be seen as division of tasks, hierarchy, division of activities and command. Such understanding can have implications for the worker's health, both in the form of well-being and manifestations of psychiatric distress symptoms, since the more controlling and rigid this organization is, more it affects the life of the worker by increasing repression and reducing the feeling of freedom and creativity, which derives from the execution of tasks8. Among police officers, the main causes of illness and absence from work are minor psychiatric disorders9, which are characterized by mild depressive symptoms, anxiety, fatigue, irritability, insomnia and deficits in memory and concentration10. These manifestations occur in response to some type of psychiatric distress and are not necessarily associated with the existence of a diagnosable organic pathology11. Studies that evaluated minor psychiatric disorders in police officers pointed out that the presence of psychiatric distress in this category is conditioned to difficult situations, daily confrontations, dissatisfaction with life, work problems and health changes8,12,13. Other factors related to the work activities were also associated with the presence of minor psychiatric disorders, such as long working hours, sociodemographic and occupational characteristics8, level of satisfaction with the ability to react to difficult situations, victimization and location of the service unit8,13. Few studies highlight the work context related to the mental health conditions of these workers14,15. It is noteworthy that the different sociodemographic profiles and working conditions can interfere with the studied outcomes, pointing to a knowledge gap regarding the study population. Therefore, this study aimed to analyze the association between the work context and the presence of minor psychiatric disorders in Civil Police officers from Porto Alegre. METHODS This method is based on a mixed, sequential and exploratory research, developing the cross-sectional quantitative and qualitative in the descriptive exploratory modality approaches. The study took place at the Civil Police of Porto Alegre, capital of Rio Grande do Sul (RS) state, south of Brazil, encompassing 12 departments that make up its division. The study population consisted of 1,540 civil police officers and the estimated sample size was 237 civil police officers. Post hoc power analysis for the present study, given the observed effects and proportion of positive cases, indicate a sensibility (1-beta) = 96%. For data collection, an identification list of Civil Police workers was used, which had the department of action. Sampling in each department was proportional to its size. Systematic random sampling was used for Civil Police departments; and cluster sampling for the Police Stations. The sampling process for the police stations resulted from the impossibility of collection in all units. Police stations from all regions of the city were included. The selection of the police stations considered the sociodemographic profile and the predominance of traumatic events and attended occurrences, which were informed by the institution to contemplate greater heterogeneity. The study included only active workers, aged between 18 and 65 years old. The exclusion criteria were: police officers who were away from their role or on license for any reason during the data collection period, as well as those who had worked less than a year in the corporation. For the qualitative stage, the “best informants” were invited, considering the participants of the quantitative stage of the study and who showed interest in participating in the interviews, composing the sample of 20 Civil Police officers from different departments and police stations, with the data saturation criterion16. Data collection took place from September 2017 to July 2018. For data collection, a questionnaire was used containing sociodemographic, lifestyle and socio-labor data. The Brazilian version of the Self-Report Questionnaire (SRQ-20)17 was used to assess minor psychiatric disorders. The instrument has 20 questions regarding the presence of symptoms and problems that have occurred in the last 30 days before the answer. The assessment encompasses four subcategories: anxious and depressive mood, somatic symptoms, decreased energy and depressive thoughts. Each alternative has the scores zero (0) and one (1), where a value of one (1) indicates that the symptoms were present in the last month, and zero (0) means absence of symptoms18. The cutoff point proposed to characterize the presence of minor psychiatric disorders was for values equal or greater than 7 points, or a greater proportion of positive answers in both genders, based on a study with police officers19. The qualitative stage took place by means of a semi-structured interview, with five open questions about the work in the civil police in Porto Alegre, physical and mental health, and strategies that can help maintain the health of civil police officers. The interviews were recorded and later transcribed. Participants were invited to participate in the research in person, and received guidance on how to fill out the form. The filling was carried out by the participants themselves, under supervision. At the end, the answers were checked to ensure the correct and complete filling of the instrument. The analysis of the quantitative data was developed with the aid of the Statistical Package for the Social Sciences (SPSS) software, version 18.0. Shapiro-Wilk normality test was performed and asymmetry and kurtosis values were obtained. The categorical variables were described by absolute and relative frequencies, while the continuous quantitative variables were described by central tendency and dispersion measures. In next stage, variables with bivariate significant associations (p < 0.05) with the dependent variable were selected for Poisson Regression Model. We estimate the prediction of minor psychiatric disorders, with 95% confidence intervals. The data from the semi-structured interviews were transcribed and subjected to thematic analysis, according to Minayo, following these stages: (a) pre-analysis, (b) exploration of the material, (c) data processing and interpretation. In the mixed analysis, the data were combined by connection between the analysis and data collection phases for each research step, the qualitative step integrating a more comprehensive approach to the numerical data (quantitative step). The study was forwarded to and approved by the Research Ethics Committee, under CAAE No. 65391717.1.0000.5347, respecting the ethical precepts according to Law 466, dated 2012, of the National Health Council (Conselho Nacional de Saúde – CNS) of Brazil. To prevent the identification of the participants, the interviewees were coded with the initials of the Civil Police (PC), followed by Arabic numbers, according to the order of the interviews (e.g.: PC1; PC2; PC3;…). RESULTS The highest percentage of Civil Police officers was male (n = 123; 51.9%), married or with partner (n = 156; 65.8%), and complete higher education course (n = 222; 94.1%). The following median values were obtained: age, 39.5 (34.5-48.0) years old; 1 (0-1) child; and 17 (16-19) years of study. As for the habits of the Civil Police officers, the highest percentage referred to diet as healthy (n = 160; 67.5%), practicing regular physical activity (n = 161; 67.9%), non-smokers (n = 218; 92%), and with weekly consumption of alcoholic beverages (n = 129; 54.4%). Regarding the health conditions, 20.7% (n = 49) were undergoing some health treatment and 34.2% (n = 81) made use of some medication. Regarding work license, 31.6% (n = 75) had already needed to be away for some reason related to physical health (n = 37; 48.75%), mental health (n = 9; 11.8%), work-related accidents (n = 10; 13.2%), and for other reasons (n = 19; 25.0%). It is also believed that 80.2% (n = 192) perceived work-related illnesses in some of their colleagues. In relation to the participants' mental health, 44.3% (n = 105) had changes in their mental health after entering the institution, and 21.1% (n = 50) sought some health treatment. As for the socio-labor data, the study evidenced that the working time median was 7 (3-16) years, the time exercising in the role was 6 (3-14) years and the workday was 8 (8-8) hours per day and 40 (40-40) hours per week. The highest percentage of professionals worked in administrative activities (n = 72; 30.4%), with a greater number of police officers in the position of clerks (n = 111; 46.8%). The smaller percentage had a second job (n = 25; 10.5%), worked overtime (n = 107; 45.1%) and worked on-call (n = 62; 26.2%). Regarding rest (n = 141; 59.5%) and leisure (n = 129; 54.4%) time, they were considered sufficient by most of the professionals. The work pace was considered moderate by 59.1% (n = 140), and the workplace as partially organized by 27% (n = 64). The number of workers on the work schedule was identified as insufficient (n = 142; 59.9%) and 62% (n = 147) of the participants did not receive training for the role they performed. Regarding exposure to violence in the workplace, 50.6% (n = 120) stated having already being victims, with psychiatric (n = 85; 35.9%) and physical (n = 24; 10.1%) violence being the most reported. When assessing the level of satisfaction with the monthly remuneration, the median was 3 (2-4); with the workplace, 4 (3-4, 5); with job recognition, 3 (2-4); with interpersonal relationships, 4 (4-5), with motivation to work, 4 (3-5); and with the concern about the risk inherent to the profession, 4 (3-5). Corroborating with quantitative data presented above, the “Work context of the Civil Police” category emerged from the qualitative interviews, divided into three subcategories: “Frantic work pace and demand for goals”; “Precarious working conditions”; and “Insufficient staff”: The police officers represent the “Frantic work pace and the demands for goals” due to amount of work and the need to meet goals: “[…] The sensation that I have is that if I close that door, I have work for the rest of my life and I wouldn't be able to handle it. It is clear that this sensation generates some anguish, right? […]” (PC6). “[…] you're already tired at the end of the year, under stress, we work with a goal, although it doesn't seem like we have goal, we have things, they are constantly pushing us and we who work with bureaucracy […]” (PC7). “[…] every day I have something to do, but for me, the most tense period is first week of each month, we have goals to meet, we have data to send in the Police statistics system, right, and these data we can't all miss, because they are data that are sent to the Public Security Secretariat to the Police Chief, to the directors, in this period that for me is more tense […]” (PC16). The “Precarious working conditions” are reported by the police officers as unhealthy work environments, material deficits: “[…] the working conditions in the Police are terrible, the Police have no staff, no infrastructure at all, because imagine you work on a 24-hour shift alone because there are no people, no air conditioning, no adequate bathroom, no conditions […]” (PC3). “[…], I think that the Police should have their own buildings. This rent issue consumes a lot because the money that is invested is sometimes old buildings that eventually don't offer the ideal conditions for a police officer to work, this ends up causing illness due to lack of structure to work […]” (PC5). “[…] the whole Police is precarious even if you work here (Police Headquarters) there are the need a lot of things, and in the police stations it's a little worse, this is general in the Police, both staff and material” (PC20). “Insufficient staff” was reported mainly by the police officers who work on duty, which contributes to the increase in work demand and in insecurity, according to the following reports: “[…] we have goal to meet, we have many things, I think you work, work, work, and you can't handle it, so I think there would have to be more people […]” (PC7). “[…] my 36-37 years as a police officer, the headcount remains the same […] the population grew and the headcount is the same […]” (PC11). When assessing the psychiatric changes in the Civil Police officers, a 26% prevalence of Minor Psychiatric Disorders (MPDs) was identified. Among the categories, feeling nervous, tense or worried was the highest scored question within the Depressive-anxious mood division (n = 116; 48.9%). With regard to the somatic symptoms, 98 (41.4%) participants reported poor sleep, 75 (31.6%) indicated the “you get tired easily” item and 66 (27.8%) mentioned “find it difficult to carry out your daily activities with satisfaction” corresponding to decreased vital energy. With regard to depressive thoughts, the most mentioned question was having lost interest in things (n = 43; 18.1%). Table 1 presents the data obtained in the bivariate analyses, in which they represent the association between sociodemographic and lifestyle variables with minor psychiatric disorders. Table 1 Association between sociodemographic variables, lifestyle and minor psychic disorders in Civil Police – Porto Alegre, RS, 2019 Variables MPD p-value Yes 62 (26%) No 175 (74%) Sex* Male 24 (19.5) 99 (80.5) 0.011 Female 38 (33.3) 76 (66.7) Age” 40 (34.8-48) 39 (34.0-47) 0.772 Belief/Religiosity* No 19 (28.8) 47 (71.2) 0.339 Yes 43 (25.1) 128 (74.9) Marital status” Single or without a partner 23 (28.4) 58 (71.6) 0.339 Married or with a partner 39 (24.1) 117 (75.9) Number of children” 0 (0 −1) 1 (0 - 2) <0.001 College* No 2 (14.3) 12 (85.7) 0.145 Yes 59 (26.6) 163 (73.4) Schooling” 17 (16-20) 17 (16-19) 0.655 Smoking* No 57 (26.1) 161(73.9) 0.587 Yes 5 (26.3) 14 (73.7) Consumption of alcoholic beverages* No 26 (24.1) 82 (75.9) 0.302 Yes 36 (27.9) 93 (72.1) Diet* Not healthy 23 (37.1) 39 (62.9) 0.002 Healthy 39 (23.2) 136 (76.8) Physical exercises* No 24 (31.6) 52 (68.4) 0.126 Yes 38 (23.6) 123 (76.4) Health treatment* No 42 (22.3) 146 (77.7) 0.009 Yes 20 (40.8) 29 (59.2) Use of medication* No 32 (20.5) 124 (79.5) 0.005 Yes 30 (37) 51 (63) Sleep” 6,5 (6-7) 7 (6-8) 0.008 Absence from work* No 33 (20.4) 129 (79.6) 0.003 Yes 29 (38.7) 46 (61.3) Illness of a colleague* No 4 (8.5) 43 (91.5) 0.001 Yes 58 (30.5) 132 (69.5) Change in mental health* No 18 (13.6) 114 (86.4) p < 0.001 Yes 44 (41.9) 61 (58.1) Psychological treatment* No 35 (18.7) 152 (81.3) p < 0.001 Yes 27 (54) 23 (46) Note: n = 237; * n (%); ” median (interquartile ranges). The data regarding the strength of the association between the selected variables (p < 0.05), estimated using the Poisson Regression Model, are presented in Table 2. It is noteworthy that the statistically significant variables in the model and which had an effect reduction in the prevalence of MPD were: having a healthy diet in 45% (p = 0.027), having more than eight hours of sleep per day in 25% (p = 0.03) and greater motivation for work in 28% (p = 0.003). The increase in the prevalence of MPD was significantly associated with the need for psychological treatment, with an occurrence 1.7 times higher (p < 0.001), and the performance of health treatment, with an increase of 75% (p = 0.047) in the occurrence of MPD. Table 2 Poisson Regression Model for variables associated with minor psychiatric disorders Variables B Sig. PR (CI95%) Health treatment Yes 0.561 0.047 1.752 (0.987 - 3.010) No Reference Psychological treatment Yes 0.995 <0.001 2.704 (1.604-4.516) No Reference Accelerated work pace Yes 0.428 0.108 1.535 (0.911-2.605) No Reference Healthy diet Yes -0.606 0.027 0.545 (0.320-0.946) No Reference Children -0.313 0.052 0.731 (0.523-0.986) Sleep -0.291 0.030 0.747 (0.574-0.971) Motivation to do the job -0.327 0.003 0.721 (0.579-0.897) Note: n = 237. PR: prevalence ratio; CI: confidence interval. In consonance with the quantitative findings on MPDs, we present the “Work and psychiatric changes” category, with the “Developing psychiatric symptoms” subcategory, in which the presence of symptoms such as anxiety, irritability, insomnia, and medical and pharmaceutical help resulting from the police work context, according to the reports: “[…] as much as I liked front-desk service, I did it every day from noon to six, enduring other people's problems, around four hour, I wanted to grab someone by the neck, I started using Bupropion at that time, out of anxiety because I wanted to kill everyone […]” (PC1). “[…] I've already had several moments of dread there too, my relatives told me that the period that I was in direct service to the public, I was much more irritated […]” (PC2). “[…] the problems here affect us a lot, because it's very intense what we do here, so you're at home and the thing doesn't leave your mind […]” (PC7). “[…] I go to the cardiologist because of insomnia […]” (PC9). A police officer also reports that he suffered an episode of violence and that this caused him to be alert, resulting in insomnia and difficulty to disconnect from work. “[…] I had a problem with a prisoner, who held me by the arms, scratched my face, he distrusted that I was alone there, at that time I was 27-28 years old […] as much as I liked of the profession I rethought quite a lot what I was doing there, after I changing of the police station, I spent about a year having trouble sleeping, because I listened to the cells padlock, because I thought the prisoners were calling me at dawn, you have a sensation that you have to be alert, because of the prisoners […]” (PC1). DISCUSSION The results of this study showed relevant factors regarding the work context and the presence of minor psychiatric disorders in civil police officers. The variables, such as: motivation to do the job, healthy eating, amount of daily sleep hours and having children show a decrease at the probability of the MPD occurrence. However, fast pace of work, health treatment and psychological treatment due to work, showed greater chances of manifesting minor psychiatric disorders. This current study showed a higher prevalence (26% chances of having MPD), when compared to the study carried out at Rio de Janeiro, Brazil (a city with 5,000,000 more people than Porto Alegre), which observed MPD in 21% of police officers8. This value is associated with dissatisfaction with personal life as a whole; with the inability to react to difficult situations at work; with health conditions, such as the presence of diseases originating from the nervous system and victimization in the workplace. In this study, among the symptoms defined by the police officers that characterize MPD are insomnia, irritability and anxiety. Corroborating with the results presented, the research with US police officers evidenced a significant association between the stressors of the police work and poor sleep quality1. It is also noteworthy in this study that sleep, as well as a healthy diet, can act as a protector against the development of minor psychiatric disorders, corroborating data from the literature that still highlight the positive relationship between the mental well-being and an adequate pattern of food intake20. A large number of public safety personnel (PSP) reported symptoms consistent with clinical insomnia. Those who had lower sleep quality were approximately 3 to almost 7 times more likely to screen positive for a mental disorder. Rates of insomnia related by PSP were more than double those previously reported in the general Canadian population21. The prevalence of probable mental disorders varied at UK police employees, with probable anxiety in 8.5%. Police employees with less healthy lifestyle habits such as smoking, high risk drinkers and those who were less likely to exercise reported higher levels of probable anxiety and depression22. Furthermore, this study presented that the civil police's working conditions are precarious, due to unhealthy work environments, reduced staff and lack of materials. In addition, data from the literature show that working with a reduced effective number is also the reality of other police officers in the state of Rio Grande do Sul. This situation overloads the professionals who are available and affects the quality of the service provided to the community23. When assessing job satisfaction of military police officers of Rio Grande do Sul state, the results indicated that frustration and resentment at the lack of recognition by superiors and the population, low wages, working conditions, quality of life and the fact that they feel permanently threatened, were unsatisfactory items within the corporations24. In addition to that, some of these aspects can trigger low motivation of the workers towards their activities, which can interfere with good performance. This converges so that the work environment is one of the factors that interfere in the work performance of a team25. The fast work pace proved to be a relevant factor in the onset of minor psychiatric disorders, which may be linked to the deficit of human resources and the high workload. A study carried out in Germany about the work resources and well-being of Civil Police officers concluded that these resources, characterized as team support, perception of justice in the work environment and shared values, play an important role in reducing the impact on emotional exhaustion and in the promotion of well-being. In other words, having a perspective aimed at improving the labor resources helps to reduce the work demands. The authors suggest that labor interventions in police contexts must focus both on reducing the work demand by recruiting employees and improving the work organization, regarding the promotion of resources for the well-being of the police officers. For this, a fair and supportive organizational climate based on shared values is necessary. Consequently, it could assist in reducing the emotional exhaustion of the police officers26. In this study, a high prevalence of police officers who suffered changes in mental health was found. However, a small percentage reported seeking health treatment. In this perspective, it is important to emphasize the importance of identifying and paying attention to these manifestations for the prevention of diseases. A North American study indicated that, among the police officers diagnosed with mental disorders, 35% underwent treatment in the past twelve months. Of those who presented latent symptoms, 17% sought treatment27. In addition to this, other studies have reported the stigma and the feeling of non-acceptance in the health services. There is an idea of the Police as a dehumanized justice force, which goes through exhaustive workdays and violence in its environment, but is demanded for its service to society. Self-stigma within the corporation itself is created, as well as a stigma arising from society28,29. The results indicate that the police officers who have children are less likely to develop minor psychiatric disorders. This evidence can be related to the family support linked to this aspect, corroborating with the study which describes that female police officers with kids reported slightly better quality of life related to mental health30. In contrast, police work can significantly affect their lives, due to the proximity to violence, the experience of taking risks and the rigidity in following the rules that mark their experience, which can impact on their affective relationships and greater coldness of feelings31. Regarding absences from work due to psychiatric disorders, the perception of family support proved to be an important resource during the leave period, in recovery and in the return to activity. This evidence corroborates the existence of an inverse association between the level of social support and psychiatric distress7. A survey conducted with Canadian police officers showed that occupational stress, mainly citing fatigue, negative comments from the public, red tape and shift work, affect quality of life in its psychological domain29. A study conducted with military police officers in Rio de Janeiro highlights that factors such as the ability to react to difficult situations, level of satisfaction with life, impairment of physical and mental health conditions, work overtime, stress in the work activities and victimization influence the development of psychiatric distress among the military police officers13. In the assessment of the mental health of the Brazilian police officers, it was evidenced that those who are not satisfied with life as a whole are also dissatisfied with their ability to react to difficult situations and are more susceptible to presenting psychiatric distress7. CONCLUSION The work context of the Civil Police officers was characterized by the presence of a frantic work pace, as well as demand for goals. The working conditions were considered as precarious, and the staffing as insufficient to meet the demands with quality and safety. The prevalence of MPDs was high. The main psychiatric symptoms reported were anxiety, irritability and insomnia, resulting from the work context of the police officers. Having a fast pace of work, undergoing some health treatment and having sought psychiatric treatment due to work have been shown to be related to a higher prevalence of minor psychiatric disorders. The variables motivation for work, healthy eating, number of daily hours of sleep and having children were related to lower prevalence of minor psychiatric disorders. In synthesis, it is hoped that the results may help to ground future research studies, facilitating more effective interventions by health professionals and government officials with the objective to provide the public security institutions with better working conditions in order to avoid mental illnesses in these professionals. ACKNOWLEDGMENT This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (Capes) – Finance Code 001 and by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) support. REFERENCES 1 Ma CC Hartley TA Sarkisian K Fekedulegn D Mnatsakanova A Owens S Influence of Work Characteristics on the Association Between Police Stress and Sleep Quality Saf Health Work 2019 10 30 38 1 Ma CC, Hartley TA, Sarkisian K, Fekedulegn D, Mnatsakanova A, Owens S, et al. Influence of Work Characteristics on the Association Between Police Stress and Sleep Quality. 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