Dealing with a fickle public and relying on gratuities for a significant portion of your income is “precarious” work that’s associated with higher risk of stress, depression, and sleep problems, according to new research.

The risks are especially high for women who work as waitresses, bartenders, and other jobs that involve tipping.

This is according a study from researchers at Oregon Health & Science University-Portland State University (OHSU-PSU) School of Public Health, published in the American Journal of Epidemiology.

“The higher prevalence of mental health problems may be linked to the precarious nature of service work, including lower and unpredictable wages, insufficient benefits, and a lack of control over work hours and assigned shifts,” said lead author Sarah Andrea, a PhD candidate in epidemiology at the OHSU-PSU School of Public Health.

What did the study find?

The study, published last month, looked at data on more than 5,300 men and women ages 24 to 33 from the National Longitudinal Study of Adolescent to Adult Health.

Women in tipped service jobs were found to have significantly greater odds of reporting a depression diagnosis or symptoms than women in nonservice work.

Some association also was seen between tipped service work and sleep problems and perceived stress among women.

“What we saw in our study was that women in service occupations have the highest burden of depression,” Andrea told Healthline. “We did not see that among men.”

Andrea said this kind of research can better help vulnerable workers.

“We need more research on what’s driving these trends, which have important implications for workplace and federal policies,” such as minimum-wage and paid family leave laws, she said.

Andrea pointed out, “Occupational health used to be just about preventing accidents, but we’re recognizing that there’s much more than that.”

Federal law allows employers to pay tipped workers as little as $2.13 per hour as long as total anticipated income equals the federal minimum wage of $7.25 per hour.

“On average, tipped workers are nearly twice as likely to live in poverty relative to untipped workers,” noted Andrea.

Some states have higher minimum wage laws and different compensation rules for tipped workers. In such states, there are fewer service workers living in poverty than in states that hew to the federal policy, research shows.

Tipped work can also be feast or famine: For every busy Saturday night that a bartender or waitress rakes in $200 in tips, there’s a dead Monday where they’re lucky to come home with $20 in pocket.

“Most people who work for tips experience regular lulls and peaks in their income, and the uncertainty can cause enough stress to make the worker suffer from anxiety and depression,” licensed mental health counselor GinaMarie Guarino told Healthline.

How working in the service industry can be taxing

Dealing with the public — having to put on a “happy face” for customers, no matter how rude or obnoxious, in hopes of getting a tip — also may play a role in higher rates of depression among service workers.

“In tipped wage jobs… it’s not just following a rubric and doing a job consistently, but the person is constantly subject to the whims of their customers and their personalities and foibles,” said Ramani Durvasula, PhD, a licensed clinical psychologist and professor of psychology at California State University, Los Angeles.

“That level of unpredictability and uncontrollability is very stressful, and higher stress is associated with poorer mental health.”

Study co-author Janne Boone-Heinonen, PhD, pointed out that trying to cater to the whims of the customer all the time can difficult for employees.

“While the idea that ‘the customer is always right’ may be a valid business plan, our study results indicate that mentality may negatively impact employee health, especially in women,” said Boone-Heinonen.

Sexual harassment on the job — whether from co-workers or customers — also disproportionately affects women.

The Restaurant Opportunities Center United, which advocates for a higher minimum wage, notes that female service workers in states that adhere to the federal minimum wage are three times more likely to report employers urging them to dress more provocatively in order to garner higher tips.

Women working in states with a guaranteed minimum wage were also half as likely to report on-the-job sexual harassment “since they do not have to accept inappropriate behavior from customers to guarantee an income,” the group reported.

“Tipped employees are more vulnerable to sexual harassment than all other classes of employees,” said Durvasula.

Working without a safety net

Lack of health benefits and child care also may play a role.

“This industry is not super friendly to women in regards to children,” said Kate Perry, former general manager at Seattle rum bar and restaurant Rumba. “It’s difficult to bring a baby to work behind a bar.”

Perry said she didn’t experience the economic stress that other service workers report, in part because she earned tips on top of a generous salary. (The minimum wage in Washington is $15 per hour.)

“Dealing with people all day every day is stressful and exhausting,” said Perry. “Walking home with $300 cash makes it worthwhile.”

Perry suggested a future study of mental health problems in the United States versus that in other countries where tipping isn’t the norm.

“Perhaps people in service have higher depression rates because this culture undervalues service,” she said.

“Being a professional server/bartender/chef in Europe is a legitimate job. Here, you’re constantly asked when you’re going to get a ‘real job.’”