Objective This paper discusses the contribution of a widely used theoretical model of the psychosocial work environment, effort–reward imbalance (ERI), to occupational health research. It highlights the development of this approach, its measurement, and its main findings over the past three decades, focusing on epidemiological investigations. Furthermore, several limitations and challenges in view of far-reaching changes of modern work are discussed.

Methods Based on systematic reviews, meta-analyses, and an extended search for key publications, this discussion paper sets out the main evidence of associations of the model`s measures with health risks, prioritizing prospective investigations. Complementing results addressing psychobiological markers as potential pathways underlying these associations, as well as findings on the model`s expansion beyond paid work, are briefly summarized.

Results Currently available findings document consistent, moderately elevated related risks of ischemic heart disease (IHD) and depression following exposure to ERI. Quasi-experimental findings on physiological parameters as potential mediators of the link with IHD support this evidence. Results on a range of other disorders, in particular metabolic diseases, drug-related disorders, and indicators of reduced health functioning, while supportive, are less robust.

Conclusions This paper synthesizes three decades of international research on ERI as a parsimonious model of adverse psychosocial working conditions. At the same time, conceptual and methodological limitations—particularly in light of rapid changes in modern work and employment—point to priorities for future refinement and application of the model.

Key terms depression; effort–reward imbalance; ERI; health; ischemic heart disease; psychosocial work environment; research; review; theoretical model; work

• Supplementary material