Military Job Stress and Mental Health

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Occupational Medicine 2012;62:182–187
Advance Access publication on 7 March 2012
doi:10.1093/occmed/kqs006
Military hierarchy, job stress and mental health in
peacetime
L. C. X. Martins
1,2
and C. S. Lopes
1
1
Department of Epidemiology, Institute of Social Medicine, State
University of Rio de Janeiro (IMS/UERJ), Rua São Francisco
Xavier 524, 7� andar, Rio de Janeiro, RJ 20550-900, Rio de
Janeiro, RJ 20550-900, Brazil, 2Department of Post-
Graduation/School
of Physical Education of Brazilian Army, Escola de Educacxão
Fı́sica do Exército—Secxão de Pós-Graduacxão, Avenida João
Luı́z Alves,
S/Nr—Urca, CEP 22291-090, Rio de Janeiro, RJ, Brazil.
Correspondence to: L. C. X. Martins, Department of Post-
Graduation/School of Physical Education of Brazilian Army,
Escola de
Educacxão Fı́sica do Exército—Secxão de Pós-Graduacxão, Av.
João Luı́z Alves, S/Nr—Urca, CEP 22291-090, Rio de Janeiro,
RJ,

Brazil. Tel: 155 21 2586 2297; fax: 155 21 2295 7745; e-mail:
[email protected] and C. S. Lopes, Department of Epidemiology,
Institute of Social Medicine, State University of Rio de Janeiro
(IMS/UERJ), Brazil Rua São Francisco Xavier 524, 7� andar,
Rio de
Janeiro, RJ 20550-900, Brazil. Tel: 155 21 2334 0472; fax: 155
21 2334 2152; e-mail: [email protected]
Background Most studies of mental health in the armed forces
focus primarily on post-traumatic stress disorders
among military personnel in combat situations.
Aims To evaluate the prevalence of common mental disorders
(CMD) and job stress, and the association
between the two, among military personnel in peacetime.
Additionally, it sought to identify occupa-
tional subgroups with higher prevalences of CMD.
Methods The study participants were 506 military personnel
from a Brazilian army directorate in Rio de Janeiro
City. CMD were evaluated using the 12-item version General
Health Questionnaire. Job character-
istics were measured using the effort-reward imbalance (ERI)
model and by categories of military
rank. Prevalence ratios (PRs) were estimated by Poisson
regression to obtain robust (95%) confidence
intervals (CIs).
Results The prevalence of CMD was 33% (95% CI 29–37).

After adjusting for age, education, income, life-
style and other occupational characteristics, ERI was associated
with CMD (PR 5 2.03; 95% CI 1.3–
3.1). Overcommitment proved to be an important component of
job stress. Independently of socio-
economic, demographic, lifestyle and job stress variables, the
rank of lieutenant associated strongly
with CMD (PR 5 2.02; 95% CI 1.2–4 0.1).
Conclusions This study found that job stress among armed
forces personnel is associated with CMD. In addition,
the specific occupational characteristics of the military
environment can lead to a higher prevalence of
CMD among those holding the rank of lieutenant.
Key words Effort-reward imbalance model; job stress; military
personnel; mental health.
Introduction
The mental health of military personnel has been studied
in developed countries, particularly those involved in
war situations [1,2], focussing on the occurrence of
post-traumatic stress disorder. Few studies have inves-
tigated mental health among the military in peacetime

[2].
The work process of military personnel has character-
istics that can have an impact on patterns of illness. Their
working environment is strongly marked by peculiarities
inherent to the military profession: rigid hierarchy,
heightened competition and the ever-present possibility
of changes occurring against the individual’s wishes.
These characteristics have been considered important
sources of job stress [2].
The relationship between state of mental health and
work environment is complex and multifaceted, and an
unfavourable work environment is associated with higher
prevalence of mental disorders [3]. Stress generally has
been pointed to as one important risk factor for the
occurrence of common mental disorders (CMD) [4], a
situation characterized by symptoms of anxiety and de-
pression, in addition to a series of non-specific and somatic
complaints. The literature indicates that service personnel

with high stress levels [2,5] or stress-related disorders suf-
fer more physical and mental morbidity, miss more days
work, are less productive and make more frequent use
� The Author 2012. Published by Oxford University Press on
behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email:
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of health services [6]. Job stress can have an overall
effect on people, leading to anxiety, exhaustion, de-
pression and even substance abuse. In addition, the

constant possibility of changes at work, against the
individual’s wishes, can precipitate additional stress
[7]. The disability caused by stress is as major as that
resulting from work accidents or other common medical
conditions [6].
Few studies have investigated mental health among
armed service personnel in peacetime. Studies in the
UK have shown prevalences of CMD ranging from
20% [8,9] to 27%, depending on the cut-off point of the
instrument used. In the US armed forces, the prevalence
was 28% [1].
Despite the peculiarities of the work process of military
personnel while performing their normal military duties
in peacetime, little is known about the role of job stress
in their mental health. Studies, conducted mainly in
the USA and UK, have shown an important association
between exposure to job stress and the occurrence of
mental disorders [1,2]. In addition, those occupying

lower ranks in the military hierarchy display more likeli-
hood of mental disorders [10].
In Brazil, the only study of stress and mental health
among armed forces personnel was performed on the
return of one contingent deployed on a peacekeeping
mission in Haiti, and it focused on post-traumatic stress
disorder [11]. In this context, as far as we know, this is the
first study to investigate the prevalence of CMD and its
association to job stress, according to the effort-reward
imbalance (ERI) model and rank among active service
personnel in peacetime.
The aims of this study were to evaluate the prevalence
of CMD and its association with job stress and rank
among military personnel in peacetime.
Methods
This was a cross-sectional census-type study of armed
forces personnel serving at a Brazilian army directorate
and its subordinate military organizations. Data

collection took place from October 2009 to February
2010.
Written informed consent was obtained from all par-
ticipants. Ethical approval was obtained from the Ethics
Committee of Rio de Janeiro State University.
Data were collected using self-completed question-
naires on socio-economic, demographic and occupational
characteristics, physical activity, self-reported health con-
ditions and self-perceived health. CMD (outcome) was
evaluated using the GHQ-12, validated in Brazil [12].
The questionnaire asks about the presence of CMD dur-
ing the previous 2 weeks. It is scored by designating each
item as absent (0) or present (1); those scoring $3 (of 12)
were classified as ‘cases’ [13].
The exposure variables were job stress and rank. Job
stress was assessed by the ERI model, which states that
an adverse work environment is characterized by both
high effort and low reward and displays a reciprocity def-

icit between ‘costs’ and ‘gains’. Such an imbalance may
lead to a state of active distress, by evoking negative emo-
tions. This model also assumes that overcommitment
(OC) (a personality characteristic) intensifies the process;
highly overcommitted workers will respond to an ERI
with more strain reactions than less overcommitted
workers [7,14]. The instrument, adapted and validated
in Brazil [15], comprises 23 questions, and the results
are expressed as scores covering three facets: effort (E),
reward (R) and OC. Each facet was analysed separately,
as was the effort-reward ratio (E/R) and the total score
(TS) from the instrument, TS 5 (E/R 1 OC) [7]. The
quadrants of the ERI model were set-up as follows:
the two lower terciles of the scores were coded as
0 (low) and the upper tercile as 1 (high), from which
the following quadrants were formed: ‘high effort and
high reward’, ‘high effort and low reward’, ‘low effort
and low reward’, ‘low effort and high reward’. ‘Low effort

and high reward’ was taken as the reference category.
With the same methodology, TS and E/R were also
dichotomized into high stress (1) and low stress (0).
Rank was categorized as follows: ‘Superior officers and
captains’ (captain, major, lieutenant-colonel, colonel and
general), ‘Lieutenants’, ‘Sergeant-Majors and Sergeants’
and ‘Corporals and Privates’.
The covariates were age, education, income, marital
status and lifestyle variables. Per capita family income
(total family income divided by the number of family
members living on that income) and categorized in Brazil-
ian minimum wages. For lifestyle, the variables investi-
gated were consumption of any alcohol in the previous
2 weeks and current smoking (dichotomous) and physical
activity. The latter was evaluated by Baecke’s Question-
naire [16], a self-completed instrument that evaluates
physical activity levels in three dimensions (occupational,
sport/leisure exercise and other leisure-time physical ac-

tivities) and expresses the levels in the form of scores. This
questionnaire was validated in Brazil [17]. For some
analyses, the total score for physical activity was dichot-
omized, considering the two upper terciles as ‘High’ and
the lower tercile as ‘Low’.
Pretest and pilot studies were conducted, with test-
retest reliability assessment, in order to guarantee the
quality of the information. For the three scales, the find-
ings show high reliability ranging from substantial to
perfect [18].
Descriptive analyses were conducted. From the
bivariate analysis (x
2
), the variables that showed a statis-
tical association (P # 0.25) with CMD were selected
for multiple analysis in order to control for possible
confounders.
L. C. X. MARTINS AND C. S. LOPES: MILITARY
HIERARCHY, JOB STRESS AND MENTAL HEALTH 183

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To evaluate the unadjusted and adjusted prevalence
ratios (PRs) and their respective 95% confidence intervals
(CIs) for the association between ERI, the E and R
quadrants, rank and CMD, Poisson regression was used,
via Generalized Linear Models, as that yields more robust
CIs. Data modelling fit was tested by the goodness-of-fit
method. Absent data were excluded from the analyses.
Data entry was performed in MSAccess/2000. Statis-

tical analyses were performed using the R Platform.
Results
There were 654 military personnel serving at the director-
ate. Of these, 68 (10%) had been deployed away from the
directorate indefinitely and were excluded. Forty-six
(8%) refused to take part and of the remaining 540, 34
(6%) were women who, being so few in number, were
withdrawn from the study. The study population there-
fore comprised of 506 participants. Their characteristics
are given in Table 1. The prevalence of at least one self-
reported physical morbidity was 42%, but none displayed
any statistically significant association with CMD.
Eighty-two (16%) respondents reported suffering from
job stress (high effort and low reward) (Table 1). Figure 1
shows the distribution of job stress by rank. The highest
prevalences can be seen among lieutenants (40%), corpo-
rals and privates (37%).
Prevalence of CMD was 33% (95% CI 29.1–37.3).

Table 1 shows this prevalence by socio-economic and
demographic characteristics, self-perceived health, life-
style components, rank and job stress in the study
population. Self-perceived health (P , 0.001) and occu-
pational physical activity (P , 0.01) were positively asso-
ciated with CMD, while sports/leisure exercise (P , 0.05)
was inversely associated with CMD (Table 1).
Table 2 shows the prevalence and the prevalence ratios
of CMD by job stress levels and by rank.
The unadjusted models showed strong association
between the rank of lieutenant and CMD. This associa-
tion did not change even after adjustment for other work
characteristics, self-rated health and lifestyle (full model)
(PR 5 2.02; 95% CI 1.2–4.1). No association was found
between other military ranks and CMD.
As regards job stress, the combination of high effort
and low reward (ERI) displayed the strongest association
with CMD in both the unadjusted and adjusted models.

In comparison with the reference quadrant (low effort
and high reward), and after adjustment for all variables
(full model), high effort and low reward displayed twice
the prevalence of CMD (full model: PR 5 2.01; 95% CI
1.3–3.1), followed by high effort and high reward (PR 5
1.87; 95% CI 1.2–2.9).
The E/R showed no association with CMD, but TS of
the ERI model did show association (PR 5 1.13; 95% CI
1.1–1.2).
Discussion
The results showed that one third of the male service per-
sonnel evaluated displayed CMD and that high effort and
low reward at work and the rank of lieutenant in the
Table 1. Characteristics of the study population and prevalence
of
CMD
Characteristic n CMD P
Cases (%)
Age NS

Up to 25 years 216 74 (34)
From 26 to 35 years 139 55 (40)
From 36 to 45 years 119 30 (25)
Above 45 years 29 8 (28)
Unknown 3
Education NS
More than 9 years of study 479 159 (33)
Up to 9 years of study 27 9 (33)
Income
a
NS
Up to 2 149 48 (32)
More 2–5 177 67 (38)
More 5–10 119 39 (33)
.10 41 9 (22)
Unknown 20
Rank ,0.001***
Superior officers and captains 95 21 (22)
Lieutenants 113 56 (50)

Sergeant-majors and sergeants 107 28 (26)
Corporals and privates 191 63 (33)
Lifestyle
b
Physical activity
c
Occupational ,0.01**
High 354 130 (37)
Low 147 34 (23)
Sports/exercises at leisure-time ,0.05*
High 344 101 (29)
Low 156 63 (40)
Other physical activity
during leisure and commuting
NS
High 380 119 (31)
Low 119 45 (38)
Self-perceived health ,0.001***
Very good 344 85 (26)
Good 169 69 (44)
Regular 24 13 (54)

Bad 1 1 (100)
Job stress
d
,0.001***
Low efforts and high rewards 284 58 (22)
Low efforts and low rewards 94 31 (35)
High efforts and high rewards 75 34 (48)
High efforts and low rewards 82 45 (55)
Characteristics of the study population and prevalence of CMD
(N 5 506), 2010.
a
Income monthly.
b
Alcohol consumption and smoking were not statistically
significant (P . 0.05).
c
Levels determined by terciles.
d
CMD.
e
Quadrants of ERI model.
Statistical significance: *P ,0.05; **P , 0.01; ***P , 0.0001.

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military hierarchy were associated with these disorders.
These associations were independent of age, schooling,
income, marital status, self-perceived health, lifestyle
and other occupational characteristics. These findings
are important in that the occurrence of CMD can entail
consequences such as reduced productivity at work and
higher rates of absenteeism [6].

The strengths of this study are that it is one of the few
to have investigated mental health in serving members of
Brazil’s armed forces and that it achieved a very good
participation rate (92%). The study population was
homogeneous (socio-economic and demographic char-
acteristics), which reduced the likelihood of residual con-
founders. In addition, the census of service personnel at
the directorate revealed a sample population with the
same socio-economic and demographic characteristics
Figure 1. Job stress according to military rank.
Table 2. Prevalence and prevalence ratios of CMD according to
levels of job stress and rank (N 5 506), 2010
Exposure levels N (%) PR unadjusted (95%) Model 1 Model 2
a
Adjusted PR (95%) Adjusted PR (95%)
Rank
Superior officers and
captains
b
21 (22) 1.00 1.00 1.00

Lieutenants 56 (50) 2.24 (1.4–3.7) 2.04 (1.2–3.5) 2.02 (1.2–4.1)
Sergeant-majors and
sergeants
28 (26) 1.18 (0.7–2.1) 1.14 (0.7–2.4) 1.33 (0.7–2.4)
Corporals and privates 63 (33) 1.49 (0.9–2.5) 1.3 (0.8–2.4) 1.57
(0.8–3.2)
Job Stress by quadrants
c
Low efforts and high
rewards
58 (22) 1.00 1.00 1.00
Low efforts and low
rewards
31 (35) 1.59 (1.0–2.5) 1.59 (1.1–2.5) 1.60 (1.1–2.5)
High efforts and high
rewards
34 (48) 2.17 (1.4–3.3) 2.04 (1.3–3.2) 1.87 (1.2–2.9)
High efforts and low
rewards

45 (55) 2.49 (1.7–3.7) 2.18 (1.4–3.3) 2.01 (1.3–3.1)
Job stress by facets
d
Effort (E) 79 (52) 1.10 (1.1–1.1) 1.06 (1.1–1.1) 1.05 (1.1–1.1)
Reward (R) 92 (28) 1.07 (1.0–1.1) 1.03 (1.0–1.1) 1.03 (1.0–1.1)
OC 69 (47) 1.15 (1.1–1.2) 1.07 (1.0–1.1) 1.07 (1.0–1.2)
Job stress by ERI
E/R
e
47 (28) 0.85 (0.6–1.2) 0.86 (0.6–1.2) 0.88 (0.6–1.2)
TS of ERI model
f
80 (47) 1.13 (1.1–1.2) 1.12 (1.1–1.2) 1.11 (1.1–1.2)
Unadjusted and adjusted PRs and respective 95% CI for the
association between levels of job stress, rank and CMD: in
military personnel of the Brazilian Army (N 5 506)
in 2010. Model 1: adjusted for lifestyle (alcohol and physical
activity). Model 2: adjusted for lifestyle, age, self-rated health
and other job characteristics. Job stress set by
quadrants, effort and reward were not included in the model
(full model).
a
Rank and job stress mutually adjusted.

b
Reference category.
c
Quadrants of the ERI model.
d
Facets of ERI model; categorized in ‘high’ and ‘low’ levels.
e
Effort–reward ratio.
f
TS of the ERI model: TS 5 E/R 1 OC.
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as the ground forces overall [19], enabling the results to
be extrapolated to the whole Brazilian army.
Some limitations of the study must be considered.
Firstly, at initial sampling (the census), the proportion
of women was far higher (6%) than in the army overall
(1.3%), which could weaken the power of the study
and we therefore excluded women from the analyses.
However, our results remained comparable to the studies
cited here because they analysed the outcomes controlling
by gender, although they do not present all results sepa-
rately by gender. Secondly, this study is based on cross-
sectional data, which are unlikely to determine the
temporal nature of the phenomena examined, restricting
the inference concerning a causal direction of the associ-
ation of job stress and military hierarchy with CMD. We
cannot exclude reverse causation where respondents with
CMD perceived their work environment as more stress-

ful. However, longitudinal studies have consistently
shown that an adverse psychosocial environment at
work is a predictive factor for psychiatric morbidities
[20,21,22]. Our findings are in agreement with the
literature. Thirdly, individuals who are suffering psycho-
logically may report working conditions more negatively
than individuals who do not display such symptoms [23].
This bias can be avoided through the strategy of clustering
the workers into occupational categories under homoge-
neous working conditions and then aggregating cases and
non-cases by these categories [24]. Those conditions
were met by the characteristics inherent to military occu-
pational categorization, thus meeting the requirements
proposed [24] for less biased analysis. Lastly, the study
was based on the GHQ-12, a screening instrument, rather
than on a standardized clinical interview, which could
yield psychiatric diagnoses. Studies have shown that asso-
ciations between work characteristics tend to be greater in

studies using standardized clinical interviews [29].
According to the ERI model, the combination of high
effort with low reward (job stress condition) [7] increases
the risks for future health outcomes and defines adverse
psychosocial work conditions. That claim has been con-
sistently corroborated in relation to mental health [25].
Our findings agree with the literature [26,20,14], showing
that ERI was associated with higher prevalence of CMD
(PR 5 2.01). A study conducted among 7766 military
[10] using the demand-control model demonstrated that
service personnel displaying job strain showed greater risk
of psychological symptoms. Other studies have shown
that military personnel with high levels of occupational
stress had significant rates of mental disorder and loss
of productivity. In the same direction, Pflanz and Ogle
[5] found that both job stress and depression were signif-
icantly associated with reduced job performance, more
days of absenteeism, greater morbidity and more negative

perceptions of superiors’ abilities.
The total score of the ERI model showed association
with CMD, indicating that OC is an important compo-
nent in overall perception of job stress. OC occurs out
of a desire for esteem and approval and can, consequently,
result in emotional exhaustion and also aggravate the
adverse effects of the situations investigated by the ERI
model [7]. ERI plus OC represents a risk for several
diseases [20], including mental disorders [3].
Our findings show that, independently of socio-
economic, demographic, lifestyle and job stress variables,
the rank of lieutenant was strongly associated with CMD,
with prevalence (50%) more than twice that of the other
officer ranks (22%). Fear et al. [10] showed that military
rank is associated with mental disorders. They found
that the category ‘commissioned officers’ was associated
with lower risk for psychological symptoms than ‘non-
commissioned officers’ and other ranks, which differs

somewhat from our findings. In an eminently hierarchical
environment, the higher the rank, the greater the plan-
ning role and, the lower the rank, the more executive ac-
tivities predominate. In such a context, the rank of
lieutenant displays certain specific characteristics: (i) it
is the lowest commissioned officer rank, the first
rank above the non-commissioned officer category
(sergeant-majors and sergeants); (ii) it has more superiors
to answer to than the other officer ranks; (iii) it is directly
responsible for the performance of duties to be carried out
by non-commissioned officers, corporals and privates;
(iv) it is the only officer rank that does guard duty, i.e.
remains in the barracks overnight on a duty roster basis,
safeguarding the security of the military unit and (v) it is
the rank most liable to undesirable geographical or func-
tional changes at work. These characteristics indicate that
there is a possibility of stress in certain differing and con-
comitant directions. In relation to the hierarchy, the need

for esteem and approval may be directed towards both
superiors and subordinates, given that it is quite common
for sergeants and sergeant-majors to have served many
more years in the armed forces than lieutenants, nearly
all of whom have been performing military duties for only
a few years. Also, the possibility of undesirable changes
at work, which is greater at the rank of lieutenant, is
established in the literature as a cause of stress [7].
The prevalence of CMD encountered (33%) was
slightly higher than found in the armed forces of devel-
oped countries: in the UK, the prevalence was 27%
[27] and in the USA, 28% [2]. The prevalence of
CMD in the overall population of developed countries
is slightly lower than in developing countries [3,28].
In Brazil, the prevalence of CMD in the general pop-
ulation ranges from 17 to 35% and varies by region. In
Rio de Janeiro, one study of 3754 civil servants found
a prevalence of 27% among men [23]. The higher prev-

alence of CMD among male military personnel can be
explained by factors such as the possibility of forced
changes at work that entail changes of function or even
relocation and can also be related to the military hierarchy,
as found in our results.
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Acknowledgements
Our thanks to the members of the Brazilian army who agreed to

take part in this study, and to the Director and Commanding
Officers of the military units involved who made it possible to
carry out this study by offering all necessary support.
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Key points
• The prevalence of common mental disorders in
the Brazilian army in peacetime was 33%, which
was higher than those found in other studies.
• The effort-reward imbalance (high effort and low
reward) at work in military personnel was strong
and independently associated (prevalence ratio 5
2.01; confidence interval 95% 1.3–3.1) to common
mental disorders.
• Common mental disorders were twice as prevalent
at the rank of lieutenant as at the other ‘commis-
sioned officer’ ranks.

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