Research report
Workplace bullying and common mental disorders:
Department of Public Health,
University of Helsinki, Helsinki,
Finland
Correspondence to
Professor Eero Lahelma, Hjelt
Institute, Department of Public
Health, PO Box 41, 00014
University of Helsinki, Finland;
eero.lahelma@helsinki.fi
Accepted 17 December 2010
Published Online First
20 January 2011
J Epidemiol Community Health 2012;66:e3. doi:10.1136/jech.2010.115212
a follow-up study
Eero Lahelma, Tea Lallukka, Mikko Laaksonen, Peppiina Saastamoinen,
Ossi Rahkonen
ABSTRACT
Background Workplace bullying has been associated
with mental health, but longitudinal studies confirming
the association are lacking. This study examined the
associations of workplace bullying with subsequent
common mental disorders 5e7 years later, taking
account of baseline common mental disorders and
several covariates.
Methods Baseline questionnaire survey data were
collected in 2000e2002 among municipal employees,
aged 40e60 years (n¼8960; 80% women; response
rate 67%). Follow-up data were collected in 2007
(response rate 83%). The final data amounted to 6830
respondents. Workplace bullying was measured at
baseline using an instructed question about being bullied
currently, previously or never. Common mental disorders
were measured at baseline and at follow-up using the
12-item version of the General Health Questionnaire.
Those scoring 3e12 were classified as having common
mental disorders. Covariates included bullying in
childhood, occupational and employment position, work
stress, obesity and limiting longstanding illness. Logistic
regression analysis was used.
Results After adjusting for age, being currently bullied at
baseline was associated with common mental disorders
at follow-up among women (OR 2.34, CI 1.81 to 3.02)
and men (OR 3.64, CI 2.13 to 6.24). The association for
the previously bullied was weaker. Adjusting for baseline
common mental disorders, the association attenuated
but remained. Adjusting for further covariates did not
substantially alter the studied association.
Conclusion The study confirms that workplace bullying
is likely to contribute to subsequent common mental
disorders. Measures against bullying are needed at
workplaces to prevent mental disorders.
INTRODUCTION
Bullying in the workplace can be characterised as
repeated insulting actions, practices and behaviours
that interfere job performance of employees and
lead the victims to feel upset, threatened and
humiliated. The victims themselves perceive being
bullied and often are in an underdog position
compared with the bully.1 2 The general assump-
tion is that bullying negatively affects the victims,
their workmates and the workplace environment,
creating ‘toxic’ atmospheres.2 3
While the general characterisation of workplace
bullying is more or less shared, there is no common
definition as yet. The terminology also varies, and
terms such as mobbing, harassment, victimisation,
emotional abuse and psychological terror at
workplace have been used as synonyms for
bullying.1 Building on earlier work, the definition
by Einarsen et al2 refers to bullying as the result of
systematic and enduring negative and intentional
acts reflecting interpersonal conflicts in which the
victim is in an inferior position and subject to
harassment, social exclusion, offending or other
negative acts affecting work tasks. Such adverse
acts give rise to negative experiences which may
undermine self-confidence as well as health and
well-being among the victims.4e7
Bullying at workplace is a relatively common
phenomenon, and its prevalence has ranged from
5% to 20% depending on the definition, measure-
ment and the population under study.6 In the
Nordic and other western European countries, the
6e12-month prevalence of workplace bullying
varied around 10%.2 6 8
Bullying is closely related to conflicts in inter-
personal relationships at workplace. Such conflicts
enhance distress, and as a result mental health
among the victims of bullying is likely to be
affected.9 As a subarea of mental health, common
mental disorders are widespread in the community
and impair normal social functioning but do not
meet diagnostic criteria.10 11 Nevertheless they are
suitable for epidemiological studies of the mental
consequences of workplace bullying. Common
mental disorders typically include feelings of
anxiety and depression,12 and are reported even by
a quarter or a third among employees depending on
the measurement.13 14
In previous studies, workplace bullying has been
associated with common mental disorders, such as
those indicated by the General Health Question-
naire (GHQ).15 Bullying has also been associated
with depressive symptoms16 and symptoms of
post-traumatic stress disorder.17 A study among
a small group of bullied patients suggested that
severe mental health repercussions are also
possible.18 While mental health has been emphas-
ised, bullying has even been associated with
physical ill health15 and cardiovascular diseases.19
While there are suggestions that workplace
bullying and common mental disorders are associ-
ated, the evidence almost exclusively hinges on
cross-sectional studies. Follow-up studies are
needed to confirm whether the hypothesis
predicting that bullying contributes to subsequent
common mental disorders is plausible. A Norwe-
gian study followed up nurses’ aides for 15 months
but found no association between being exposed to
bullying and subsequent symptoms of anxiety
and depression.20 A Finnish study, in contrast,
following up hospital employees over 2 years found
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that those who had been bullied reported subsequent depres-
sion.19 Nevertheless, in the latter study not only did bullying
predict depression but also depression predicted bullying. Thus,
bullying may contribute to common mental disorders, but
stigmatising health problems or personality features may also
contribute to falling subject to bullying.18 19 21 22
A further question is what factors might shape the mental
repercussions of workplace bullying. Factors potentially
affecting either common mental disorders or bullying, or both,
include prior mental disorders,21 occupational and employment
position,8 23 work stress24 as well as obesity and chronic
illness.19 Childhood adversities in general and school bullying in
particular are likely to have long-lasting consequences. Based on
retrospective information, it has been suggested that those
reporting school bullying are also at risk of adult workplace
bullying.25
Relying on longitudinal data among middle-aged municipal
employees, this study first aimed to examine the association of
workplace bullying at baseline with subsequent common mental
disorders at follow-up 5e7 years later. The second aim was to
examine whether common mental disorders at baseline influence
this association. The third aim was to examine whether further
covariates, including bullying in childhood, occupational and
employment position, work stress, obesity and limiting long-
standing illness influence the studied association of workplace
bullying with common mental disorders.
MATERIALS AND METHODS
This study is part of the Helsinki Health Study examining
health and well-being among the employees of the City of
Helsinki, the largest workplace in Finland, with about 40 000
employees. The majority of the employees (72%) are women.
The main branches include public administration, social welfare,
healthcare, education, cultural services, public transportation,
environmental and technical maintenance. The jobs represent
more than 200 occupational titles across the socio-economic
ladder.
Data sources
The data were derived from mail surveys among the staff of the
City of Helsinki. The baseline data were collected in 2000, 2001
and 2002 among those who each year reached the age of 40, 45,
50, 55 and 60 years. The baseline data amounted to 8960
respondents (response rate 67%).26 The follow-up survey was
conducted 5e7 years later in 2007 among the respondents to the
baseline survey, and amounted to 7332 respondents (response
rate 83%). The data with full information for analyses included
6830 respondents. For the baseline survey, an analysis of non-
response has been conducted showing that the data are generally
representative of the target population, with men, younger
people and manual workers as well as those on long sick leaves
being slightly under-represented among the respondents.27
Workplace bullying
Workplace bullying was measured at baseline using a similar
procedure as in many prior studies.19 28 29 The instruction in the
questionnaire read: ‘Mental violence or workplace bullying refers
to isolation of a team member, underestimation of work
performance, threatening, talking behind one’s back or other
pressurizing.’ It was then asked whether the respondent had
been subject to such bullying. The response alternatives were:
never; yes, currently; yes, previously in this workplace; yes,
previously in another workplace; and cannot say. The two
categories of previous bullying were collapsed.
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Common mental disorders
Both at baseline and at follow-up, the 12-item version of the
General Health Questionnaire (GHQ-12) was used to measure
common mental disorders following Goldberg’s original
terminology for the instrument.10 11 GHQ-12 is a reliable and
well-validated epidemiological and screening instrument based
on self-reports. It primarily reflects general, non-psychotic and
context-free affective ill health over the past 4 weeks. It predicts
more severe mental disorders but does not provide diagnostic
criteria.10e12 The items of the GHQ-12 cover mainly feelings of
anxiety and depression but do not include, for example,
substance abuse. The measure gives a quantitative estimate
along a dimension ranging from scores 0 to 12 (Cronbach
a 0.91). As recommended by validation assessments, the cut-off
point of 3e12 GHQ-12 symptoms was used to indicate
common mental disorders.10 30 31
Covariates
The data were stratified by gender. Age was included as a cova-
riate. Childhood bullying was elicited at baseline by a question
asking whether the respondents before their 16th birthday had
been subject to repeated bullying in school or among fellows.
Occupational class included managers and professionals, semi-
professionals, routine non-manual employees and manual
workers.26 Employment status included those employed and
those non-employed at follow-up. Job strain indicating work-
related stress was assessed at baseline by Karasek’s job strain
inventory.32 Job demands and job control were cross-tabulated
to yield categories of low strain, active job, passive job and high
strain. A body mass index of 30 or more was used to indicate
obesity. Limiting longstanding illness was asked at baseline by
a question ‘Do you have any longstanding illness, disability or
infirmity?’ and a following question ‘Does your illness/disability
restrict your work or does it limit your daily activities (gainful
employment, housework, schooling, studying)?’ A positive
response to both questions implied limiting longstanding illness.
Statistical analysis
Prevalence percentages for workplace bullying and common
mental disorders were calculated. Table 1 presents prevalence
percentages for bullying by gender, age and occupational class
including p values from c2 tests. Next, associations of bullying
at baseline with common mental disorders at follow-up were
examined using logistic regression analysis. Variables were
entered into the models as categorical. First, ORs adjusted for
age only were calculated. Second, baseline common mental
disorders were additionally adjusted for to eliminate any prior
mental disorders that might have contributed to workplace
bullying at baseline. Third, after adjusting for age and baseline
common mental disorders, further covariates were adjusted for
each one at a time.
RESULTS
The prevalence of being currently bullied was 5% for both
women and men (table 1). Nineteen per cent of women and 13%
of men had been previously bullied in the current or in another
workplace. Eleven per cent of women and 10% of men reported
being unable to say whether they had been bullied or not. The
rest had never been bullied. There were small variations in
bullying by age and occupational class, but no clear patterns
could be observed.
Among women, the prevalence of common mental disorders,
that is, a GHQ-12 score of 3e12, was 25% at baseline and 24%
J Epidemiol Community Health 2012;66:e3. doi:10.1136/jech.2010.115212
 Research report

Table 1 Prevalence (%) of bullying among women and men by age and were unable to say whether they had been bullied or not were
occupational class more likely to report common mental disorders. Among men as
Bullying well, after adjusting for baseline common mental disorders, the
Currently Previously Cannot Never All currently bullied at baseline were still more likely, although
(%) (%) say (%) (%) (%) N a third less so, to report common mental disorders at follow-up.
Women The associations of both previous bullying and being unable to
Age report bullying with common mental disorders attenuated but
40 4 16 10 69 100 1134 remained. There was a strong association of common mental
45 3 19 11 67 100 1195 disorders at baseline with common mental disorders at follow-
50 7 21 11 62 100 1243 up (OR 4.22, CI 3.11 to 5.74) as found for women as well (data
55 5 19 10 65 100 1392 not shown). Further covariates were adjusted for in accordance
60 5 21 9 65 100 646 with the procedure followed among women. Only limiting
All 5 19 11 65 100 5610 longstanding illness slightly attenuated the studied association
c2 test, p<0.0007 between bullying and subsequent common mental disorders.
Occupational class
Professional 6 19 12 62 100 617
DISCUSSION
Semiprofessional 5 19 12 64 100 2344
This longitudinal study sought to examine whether workplace
Routine non- 4 20 10 65 100 1099
manual bullying at baseline is associated with common mental disorders
Manual 5 18 8 69 100 1550 at follow-up 5e7 years later among middle-aged employees of
c2 test, p<0.0003 the City of Helsinki. The main findings can be summarised
Men under the following points.
Age First, among both women and men, workplace bullying at
40 3 17 9 70 100 212 baseline was associated with common mental disorders at
45 3 12 13 72 100 234 follow-up. This held true in particular for those who reported
50 6 17 9 68 100 254 being currently bullied and less so among those who had been
55 6 9 10 75 100 369 previously bullied. Second, taking baseline common mental
60 6 14 10 70 100 211 disorders into account weakened but did not abolish the asso-
All 5 13 10 71 100 1280 ciation of bullying with common mental disorders. Third, taking
c2 test, p<0.11 further covariates into account did not substantially alter the
Occupational class studied association. Thus, the associations between bullying and
Professional 5 15 14 66 100 314 subsequent common mental disorders remained among both
Semiprofessional 7 16 8 68 100 130
women and men throughout the analysis.
Routine non- 4 11 11 74 100 250
manual
Interpretation
Manual 5 13 9 74 100 586
The main findings are in accordance with assumptions based on
c2 test, p<0.13
prior work, as our study demonstrated that workplace bullying
is associated with subsequent common mental disorders. The
previous evidence is almost exclusively derived from cross-
at follow-up; for men, the corresponding figures were 22% and sectional studies,15 16 whereas our evidence is longitudinal and
20%. comes from a prospective follow-up. The previous longitudinal
Logistic regression analysis showed that compared with the evidence is limited and has either lacked standardised instru-
never bullied, currently bullied (OR 2.34, 1.81 to 3.02) or ments of common mental disorders19 or been focused on
previously bullied women (OR 1.64, CI 1.41 to 1.91) were more a specific occupational group.20 Compared with earlier research
likely to report common mental disorders at follow-up after our study yields stronger evidence on the role of workplace
adjusting for age (table 2). Women who were unable to say bullying as contributing to common mental disorders than has
whether they had been bullied or not were also somewhat more been available so far.
likely to report common mental disorders. After adjusting for The gender patterning of the mental health repercussions of
baseline common mental disorders, the association between bullying has been practically neglected. In a French study, the
being currently bullied and common mental disorders at follow- association of bullying and depressive symptoms was very
up attenuated by about a third. The association of previous similar among both women and men.16 In our study as well, the
bullying with common mental disorders also attenuated. There association of bullying with common mental disorders was
was a strong association of common mental disorders at baseline observed among both women and men, with the association
with common mental disorders at follow-up (OR 3.53, CI 3.08 being particularly strong among men. While it is likely that both
to 4.04) (data not shown). Next, the effects of further covariates genders suffer from mental health repercussions of bullying,
were examined one at a time after adjusting for age and common more work is needed on gender differences in the production of
mental disorders at baseline. Childhood bullying, occupational mental disorders as a consequence of workplace bullying.
class, employment status, job strain, obesity and limiting long- Our analyses showed that taking baseline common mental
standing illness had no effects worth mentioning on the asso- disorders into account weakened the original association of
ciation between bullying and common mental disorders among workplace bullying with subsequent common mental disorders.
women. Mental repercussions of bullying have been focused on, but an
For men as well, the currently bullied (OR 3.64, CI 2.13 to association the other way round is also possible.19 21 Thus, prior
6.24) or previously bullied (OR 1.78, CI 1.21 to 2.63) were more mental or other stigmatising health-related problems might
likely than the never bullied to report subsequent common provide a route to subsequent bullying. Bullying and mental
mental disorders after adjusting for age (table 3). Also, men who disorders may even interact over time if mentally vulnerable

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Table 2 Associations of workplace bullying at baseline (2000e2002) with common mental disorders at follow-up (2007) among women (n¼5610)
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 Model 8
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Never 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Previously 1.64 (1.41 to 1.91) 1.46 (1.25 to 1.72) 1.42 (1.21 to 1.67) 1.47 (1.25 to 1.72) 1.46 (1.25 to 1.72) 1.41 (1.20 to 1.66) 1.46 (1.25 to 1.72) 1.41 (1.17 to 1.65)
Currently 2.34 (1.81 to 3.02) 1.62 (1.24 to 2.12) 1.56 (1.19 to 2.05) 1.61 (1.23 to 2.12) 1.61 (1.23 to 2.10) 1.51 (1.15 to 1.99) 1.61 (1.23 to 2.11) 1.53 (1.20 to 2.01)
Cannot say 1.48 (1.21 to 1.80) 1.28 (1.05 to 1.57) 1.25 (1.02 to 1.54) 1.28 (1.04 to 1.57) 1.28 (1.04 to 1.57) 1.23 (1.00 to 1.51) 1.28 (1.04 to 1.57) 1.25 (1.01 to 1.53)
ORs and their 95% CIs adjusting for covariates. Model 1: +age. Model 2: Model 1+baseline common mental disorders. Model 3: Model 2+childhood bullying. Model 4: Model 2+occupational
class. Model 5: Model 2+employment status. Model 6: Model 2+job strain. Model 7: Model 2+obesity. Model 8: Model 2+limiting longstanding illness.

people are stigmatised and become victims of bullying, with this
further contributing to their mental disorders. For control
purposes, cross-sectional analyses of bullying and common
mental disorders both at baseline and at follow-up were made.
The associations at both time points, among women as well as
men, were very similar, the main difference from the longitu-
dinal ones being that the longitudinal associations were some-
what stronger. Our study reconfirms the complex pathways
between bullying and mental health, pinpointing the need for
future clarification of the associations.
Over and above the influence of baseline common mental
disorders, the studied association of workplace bullying with
common mental disorders was practically immune to the
influences of further covariates. Thus, the bullied victims were
more likely to report subsequent common mental disorders than
their never bullied counterparts, irrespective of bullying in
childhood, socio-economic factors, psychosocial stress, obesity
and chronic illness. Also, in previous studies, the association of
bullying with mental disorders has remained after considering
covariates, although the variety of covariates in our study was
broader than in the previous studies.16 19
We measured common mental disorders with the General
Health Questionnaire, which is a very frequently used, reliable
and valid instrument reflecting primarily milder and widespread
disorders but also predicting more severe disorders and the need
for treatment.10e12 30 In addition to the conventional cut-off
point (scores 3e12) for common mental disorders, control
analyses were made with more severe cut points (5e12 and
7e12), but these yielded practically identical results (data not
shown). Nevertheless, the 12-item instrument used by us is
a generic one which cannot distinguish between subdomains of
mental disorders. Furthermore, the General Health Question-
naire relies on self-reports. Therefore, future examinations
would benefit from additional mental outcomes based on diag-
noses, treatment and psychotropic medication in order to be able
to confirm bullying as a factor contributing to mental disorders
varying in nature and severity.
Examining employees from a large municipal workplace,
a broad coverage of white-collar and blue-collar occupations
were included. Nevertheless, the target was only one single,
albeit large, workplace. Thus, caution is needed in extending the
results even to the public sector, to say nothing about the labour
market in general. The evidence from different occupational
contexts might nevertheless be taken as a suggestion for the
mental health repercussions of bullying not necessarily being
strongly employment-sector- or occupation-specific,15 19 20 but
further work is warranted.
Methodological considerations
This study included a longitudinal design, large sample, reliable
measurement of common mental disorders and a broad variety
of covariates. The follow-up, that, is 5e7 years, is relatively
long, and the participants may have experienced other adverse
life events influencing their mental health. The participation to
the baseline survey was satisfactory, and according to our non-
response analysis, the data were largely representative of the
target population.27 The participation to the follow-up survey
was high, leaving less room for bias.
The measurement of bullying followed a similar, although
relatively simple, procedure to that in a number of previous
studies.19 28 29 Bullying is a multidimensional construct, and
while the instruction of our measure covers various dimensions,
they cannot be examined separately. Neither can we measure the
severity or the duration of bullying. There are more elaborate
measures such as the Negative Acts Questionnaire4 and the
Leymann Inventory of Psychological Terror,16 but no measure is
yet generally approved and this complicates comparisons
between studies. The measurement of bullying used by us has
produced findings which are in accordance with studies
following a similar as well more elaborate measurement.
Our measure of bullying yielded an additional potentially
important finding, as about a 10th of the respondents were
unable say whether they had been bullied or not. These
respondents were also somewhat more likely to report common
mental disorders than the never bullied. Bullying at workplace
is a sensitive issue, and some victims may find it difficult
to acknowledge for themselves or other people that they have
been subject to such humiliating behaviour. If some victims
choose to deny bullying, part of the repercussions may also
remain hidden as previously noted as well.7 This source of bias
should be considered in future work. More objective measures
include asking about bullying from workmates or other
observers.33
Bullying elicited in surveys is strongly based on people’s own
experience and so are common mental disorders. Self-reports are
useful and often the only option in large-scale studies.

Table 3 Associations of workplace bullying at baseline (2000e2002) with common mental disorders at follow-up (2007) among men (n¼1280)
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 Model 8
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Never 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Previously 1.78 (1.21 to 2.63) 1.55 (1.03 to 2.33) 1.48 (0.98 to 2.25) 1.51 (1.00 to 2.28) 1.54 (1.02 to 2.32) 1.54 (1.02 to 2.33) 1.55 (1.03 to 2.33) 1.42 (0.94 to 2.15)
Currently 3.64 (2.13 to 6.24) 2.41 (1.35 to 4.30) 2.28 (1.27 to 4.09) 2.34 (1.31 to 4.18) 2.40 (1.35 to 4.28) 2.36 (1.32 to 4.21) 2.38 (1.33 to 4.24) 2.12 (1.18 to 3.81)
Cannot say 2.02 (1.32 to 3.07) 1.66 (1.07 to 2.59) 1.64 (1.05 to 2.55) 1.62 (1.04 to 2.53) 1.67 (1.07 to 2.60) 1.65 (1.05 to 2.57) 1.65 (1.06 to 2.57) 1.64 (1.05 to 2.55)
ORs and their 95% CIs adjusting for covariates. Model 1: +age. Model 2: Model 1+baseline common mental disorders. Model 3: Model 2+childhood bullying. Model 4: Model 2+occupational
class. Model 5: Model 2+employment status. Model 6: Model 2+ job strain. Model 7: Model 2+ obesity. Model 8: Model 2+ limiting longstanding illness.

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What is already known on this subject
< Previous studies suggest that there is an association between
workplace bullying and mental disorders.
< However, the evidence is mostly cross-sectional, and
longitudinal studies are needed to establish the direction of
the association found.
What this study adds
< This longitudinal study confirms that workplace bullying is
associated with subsequent common mental disorders.
< The association remains, even after considering prior mental
disorders and several other covariates.
Nevertheless, self-reports need to be critically assessed for
potential bias. Personality factors such as negative affectivity,
that is a disposition reflecting negative emotionality and self-
concept, may lead to overtly negative responses to question-
naires.17 34 In contrast to denying bullying, negative affectivity
might rather overestimate the problem.35
CONCLUSION
Using a longitudinal design and ruling out the influence of
several covariates, our study confirms that prior workplace
bullying is likely to contribute to subsequent common mental
disorders. More objective measures reflecting more severe mental
disorders would be beneficial for corroborating the current
findings based on self-reports of common mental disorders.
Bullying at workplaces is relatively common. Organisational
policies and occupational healthcare need to minimise the
adverse health outcomes related to workplace bullying. Super-
visory training should include the recognition of the signs of
bullying, as well as guidelines to follow when dealing with
the problem. Successful tackling of bullying behaviours at
workplaces would help safeguard employee mental health and
functioning.
Acknowledgements Thanks to the City of Helsinki and all members of the Helsinki
Health Study group.
Funding Academy of Finland 1121748, 1129225, 1135630, Finnish Work Environment
Fund 106065, Helsinki, Finland.
Competing interests None.
Patient consent Obtained.
Ethics approval Ethics approval was provided by the ethics committees of the
Department of Public Health, University of Helsinki and the health authorities of the
City of Helsinki, Finland.
Provenance and peer review Not commissioned; externally peer reviewed.
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