Interventions to improve return to work in depressed people

Effectiveness of conservative interventions for sickness and pain behaviors induced by a high repetition high force upper extremity task

Background

Systemic inflammation is known to induce sickness behaviors, including decreased social interaction and pain. We have reported increased serum inflammatory cytokines in a rat model of repetitive strain injury (rats perform an upper extremity reaching task for prolonged periods). Here, we sought to determine if sickness behaviors are induced in this model and the effectiveness of conservative treatments.

Methods

Experimental rats underwent initial training to learn a high force reaching task (10 min/day, 5 days/week for 6 weeks), with or without ibuprofen treatment (TRHF vs. TRHF + IBU rats). Subsets of trained animals went on to perform a high repetition high force (HRHF) task for 6 or 12 weeks (2 h/day, 3 days/week) without treatment, or received two secondary interventions: ibuprofen (HRHF + IBU) or a move to a lower demand low repetition low force task (HRHF-to-LRLF), beginning in task week 5. Mixed-effects models with repeated measures assays were used to assay duration of social interaction, aggression, forepaw withdrawal thresholds and reach performance abilities. One-way and two-way ANOVAs were used to assay tissue responses. Corrections for multiple comparisons were made.

Results

TRHF + IBU rats did not develop behavioral declines or systemic increases in IL-1beta and IL-6, observed in untreated TRHF rats. Untreated HRHF rats showed social interaction declines, difficulties performing the operant task and forepaw mechanical allodynia. Untreated HRHF rats also had increased serum levels of several inflammatory cytokines and chemokines, neuroinflammatory responses (e.g., increased TNFalpha) in the brain, median nerve and spinal cord, and Substance P and neurokinin 1 immunoexpression in the spinal cord. HRHF + IBU and HRHF-to-LRLF rats showed improved social interaction and reduced inflammatory serum, nerve and brain changes. However, neither secondary treatment rescued HRHF-task induced forepaw allodynia, or completely attenuated task performance declines or spinal cord responses.

Conclusions

These results suggest that inflammatory mechanisms induced by prolonged performance of high physical demand tasks mediate the development of social interaction declines and aggression. However, persistent spinal cord sensitization was associated with persistent behavioral indices of discomfort, despite use of conservative secondary interventions indicating the need for prevention or more effective interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12868-017-0354-3) contains supplementary material, which is available to authorized users.

Maintaining employment and improving health

Purpose

A proportion of the working age population in the UK experience mental health conditions, with this group often facing significant challenges to retain their employment. As part of a broader political commitment to health and well-being at work, the use of job retention services have become part of a suite of interventions designed to support both employers and employees. While rigorous assessment of job retention programmes are lacking, the purpose of this paper is to examine the success of, and distils learning from, a job retention service in England.

Design/methodology/approach

A qualitative methodology was adopted for this research with semi-structured interviews considered an appropriate method to illuminate key issues. In total, 28 individuals were interviewed, including current and former service users, referrers, employers and job retention staff.

Findings

Without the support of the job retention service, employees with mental health conditions were reported unlikely to have been maintained their employment status. Additional benefits were also reported, including improved mental health outcomes and impacts on individuals’ personal life. Employers also reported positive benefits in engaging with the job retention service, including feeling better while being able to offer appropriate solutions that were mutually acceptable to the employee and the organisation.

Originality/value

Job retention programmes are under researched and little is known about their effectiveness and the mechanisms that support individuals at work with mental health conditions. This study adds to the existing evidence and suggests that such interventions are promising in supporting employees and employers.

Anxiety and depression predict musculoskeletal disorders in health care workers

Incidence of musculoskeletal disorders (MSDs) is high among health care workers (HCWs). To determine whether MSDs are associated with preexisting anxiety and/or depression, a case-control study was carried out in female HCWs (56 cases/55 controls). Cases were HCWs with a first-time clinical diagnosis of MSD within the previous 2 years. Occupation, workplace, work shift, direct patient assistance, and anxiety/depression scores (Goldberg scale) were assessed. Increased risk of incident MSDs (multivariate logistic regression) was found in workers with preexisting anxiety/depression compared to those without (OR 5.01; 95% CI 2.20-12.05; p < .01). Other significant risk factors were direct patient assistance (OR 2.59; 95% CI 1.03-6.92; p = .04) and morning work shift (OR 2.47; 95% CI 0.99-6.48; p = .05). Preexisting anxiety/depression was associated with incident MSDs in HCWs, adjusting for occupational exposure risk factors.

Effectiveness of psychotherapeutic consultation in the workplace: a controlled observational trial

BACKGROUND

This study compares the effectiveness of psychotherapeutic consultation in the workplace (PSIW) with psychotherapeutic outpatient care (PSOC) in Germany.

METHODS

Work ability (WAI), quality of life (SF-12), clinical symptoms (PHQ) and work-related stress (MBI, IS) were assessed in 367 patients seeking mental health care via two routes (PSIW n = 174; PSOC n = 193) before consultation and 12 weeks later. Changes in outcome variables were assessed using covariance analysis with repeated measures (ANCOVA) with sociodemographic variables (propensity score method), therapy dose, setting and symptom severity as covariates.

RESULTS

The PSIW and PSOC groups included 122 and 66 men respectively. There were 102 first-time users of mental healthcare in the PSIW group and 83 in the PSOC group. There were group differences in outcome variables at baseline (p < 0.05); PSIW patients were less impaired overall. There were no group difference in sociodemographic variables, number of sessions within the offer or symptom severity. There was no main effect of group on outcome variables and no group*time interaction. Work-related stress indicators did not change during the intervention, but work ability improved in both groups (F = 10.149, p = 0.002; baseline M = 27.2, SD = 8.85); follow-up M = 28.6, SD = 9.02), as did perceived mental health (SF-12 MCS), depression (PHQ-9) and anxiety (PHQ-7). Effect sizes were between η(2) = 0.028 and η(2) = 0.040.

CONCLUSIONS

Psychotherapeutic consultation is similarly effective in improving patients' functional and clinical status whether delivered in the workplace or in an outpatient clinic. Offering mental health services in the workplace makes it easier to reach patients at an earlier stage in their illness and thus enables provision of early and effective mental health care.

TRIAL REGISTRATION

DRKS00003184 , retrospectively registered 13 January 2012.

What incentives influence employers to engage in workplace health interventions?

BACKGROUND

To achieve a sustainable working life it is important to know more about what could encourage employers to increase the use of preventive and health promotive interventions. The objective of the study is to explore and describe the employer perspective regarding what incentives influence their use of preventive and health promotive workplace interventions.

METHOD

Semi-structured focus group interviews were carried out with 20 representatives from 19 employers across Sweden. The economic sectors represented were municipalities, government agencies, defence, educational, research, and development institutions, health care, manufacturing, agriculture and commercial services. The interviews were transcribed verbatim and the data were analysed using latent content analysis.

RESULTS

Various incentives were identified in the analysis, namely: "law and provisions", "consequences for the workplace", "knowledge of worker health and workplace health interventions", "characteristics of the intervention", "communication and collaboration with the provider". The incentives seemed to influence the decision-making in parallel with each other and were not only related to positive incentives for engaging in workplace health interventions, but also to disincentives.

CONCLUSIONS

This study suggests that the decision to engage in workplace health interventions was influenced by several incentives. There are those incentives that lead to a desire to engage in a workplace health intervention, others pertain to aspects more related to the intervention use, such as the characteristics of the employer, the provider and the intervention. It is important to take all incentives into consideration when trying to understand the decision-making process for workplace health interventions and to bridge the gap between what is produced through research and what is used in practice.

Occupational Physicians' Reasoning about Recommending Early Return to Work with Work Modifications

Previous research indicates that work modifications can effectively enhance return to work (RTW) at an early stage of work disability. We aimed to examine how occupational physicians (OPs) reason about recommending early return to work (RTW) with work modifications. Pre-defined propositions regarding the use of work modifications in promoting early RTW were discussed in four focus groups with altogether 11 Finnish OPs. Discussions were audio recorded, and the transcribed data were analyzed using qualitative content analysis. Five different rationales for supporting early RTW were identified: to manage medical conditions, to enhance employee well-being, to help workplace stakeholders, to reduce costs to society, and to enhance OP's own professional fulfillment. However, OPs identified situations and conditions in which early RTW may not be suitable. In addition, there were differences between the OPs in the interpretation of the rationales, suggesting variation in clinical practice. In conclusion, encouraging early RTW with work modifications was perceived by OPs as a meaningful task and, to a large extent, beneficial for employees and several stakeholders. However, this practice was not accepted without consideration to the RTW situation and context. If early RTW and work modifications are to be promoted, OPs should be offered education that addresses their views regarding this practice.

Scaling-up treatment of depression and anxiety: a global return on investment analysis

BACKGROUND

Depression and anxiety disorders are highly prevalent and disabling disorders, which result not only in an enormous amount of human misery and lost health, but also lost economic output. Here we propose a global investment case for a scaled-up response to the public health and economic burden of depression and anxiety disorders.

METHODS

In this global return on investment analysis, we used the mental health module of the OneHealth tool to calculate treatment costs and health outcomes in 36 countries between 2016 and 2030. We assumed a linear increase in treatment coverage. We factored in a modest improvement of 5% in both the ability to work and productivity at work as a result of treatment, subsequently mapped to the prevailing rates of labour participation and gross domestic product (GDP) per worker in each country.

FINDINGS

The net present value of investment needed over the period 2016-30 to substantially scale up effective treatment coverage for depression and anxiety disorders is estimated to be US$147 billion. The expected returns to this investment are also substantial. In terms of health impact, scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period. Placing an economic value on these healthy life-years produces a net present value of $310 billion. As well as these intrinsic benefits associated with improved health, scaled-up treatment of common mental disorders also leads to large economic productivity gains (a net present value of $230 billion for scaled-up depression treatment and $169 billion for anxiety disorders). Across country income groups, resulting benefit to cost ratios amount to 2·3-3·0 to 1 when economic benefits only are considered, and 3·3-5·7 to 1 when the value of health returns is also included.

INTERPRETATION

Return on investment analysis of the kind reported here can contribute strongly to a balanced investment case for enhanced action to address the large and growing burden of common mental disorders worldwide.

FUNDING

Grand Challenges Canada.

Employer Best Practice Guidelines for the Return to Work of Workers on Mental Disorder-Related Disability Leave: A Systematic Review

OBJECTIVE

There has been an increasing number of employer best practice guidelines (BPGs) for the return to work (RTW) from mental disorder-related disability leave. This systematic review addresses 2 questions: 1) What is the quality of the development and recommendations of these BPGs? and 2) What are the areas of agreement and discrepancy among the identified guidelines related to the RTW from mental illness-related disability leave?

METHOD

A systematic literature search was performed using publically available grey literature and best practice portals. It focused on the RTW of workers with medically certified disability leave related to mental disorders. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) was used to assess the quality of the development and recommendations of these BPGs.

RESULTS

A total of 58 unique documents were identified for screening. After screening, 5 BPGs were appraised using AGREE II; 3 BPGs were included in the final set. There were no discrepancies among the 3, although they were from different countries. They all agreed there should be: 1) well-described organizational policies and procedures for the roles and responsibilities of all stakeholders, 2) a disability leave plan, and 3) work accommodations. In addition, one guideline suggested supervisor training and mental health literacy training for all staff.

CONCLUSION

Although there were no discrepancies among the 3 BPGs, they emphasized different aspects of RTW and could be considered to be complementary. Together, they provide important guidance for those seeking to understand employer best practices for mental illness-related disability.

Cognitive Deficits as a Mediator of Poor Occupational Function in Remitted Major Depressive Disorder Patients

Cognitive deficits in major depressive disorder (MDD) patients have been described in numerous studies. However, few reports have aimed to describe cognitive deficits in the remitted state of MDD and the mediational effect of cognitive deficits on occupational outcome. The aim of the current review is to synthesize the literature on the mediating and moderating effects of specific domains of cognition on occupational impairment among people with remitted MDD. In addition, predictors of cognitive deficits found to be vocationally important will be examined. Upon examination of the extant literature, attention, executive function and verbal memory are areas of consistent impairment in remitted MDD patients. Cognitive domains shown to have considerable impact on vocational functioning include deficits in memory, attention, learning and executive function. Factors that adversely affect cognitive function related to occupational accommodation include higher age, late age at onset, residual depressive symptoms, history of melancholic/psychotic depression, and physical/psychiatric comorbidity, whereas higher levels of education showed a protective effect against cognitive deficit. Cognitive deficits are a principal mediator of occupational impairment in remitted MDD patients. Therapeutic interventions specifically targeting cognitive deficits in MDD are needed, even in the remitted state, to improve functional recovery, especially in patients who have a higher risk of cognitive deficit.

Workplace interventions to prevent work disability in workers on sick leave

BACKGROUND

Work disability has serious consequences for individuals as well as society. It is possible to facilitate resumption of work by reducing barriers to return to work (RTW) and promoting collaboration with key stakeholders. This review was first published in 2009 and has now been updated to include studies published up to February 2015.

OBJECTIVES

To determine the effectiveness of workplace interventions in preventing work disability among sick-listed workers, when compared to usual care or clinical interventions.

SEARCH METHODS

We searched the Cochrane Work Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO databases on 2 February 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of workplace interventions that aimed to improve RTW for disabled workers. We only included studies where RTW or conversely sickness absence was reported as a continuous outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias of the studies. We performed meta-analysis where possible, and we assessed the quality of evidence according to GRADE criteria. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 RCTs with 1897 workers. Eight studies included workers with musculoskeletal disorders, five workers with mental health problems, and one workers with cancer. We judged six studies to have low risk of bias for the outcome sickness absence.Workplace interventions significantly improved time until first RTW compared to usual care, moderate-quality evidence (hazard ratio (HR) 1.55, 95% confidence interval (CI) 1.20 to 2.01). Workplace interventions did not considerably reduce time to lasting RTW compared to usual care, very low-quality evidence (HR 1.07, 95% CI 0.72 to 1.57). The effect on cumulative duration of sickness absence showed a mean difference of -33.33 (95% CI -49.54 to -17.12), favouring the workplace intervention, high-quality evidence. One study assessed recurrences of sick leave, and favoured usual care, moderate-quality evidence (HR 0.42, 95% CI 0.21 to 0.82). Overall, the effectiveness of workplace interventions on work disability showed varying results.In subgroup analyses, we found that workplace interventions reduced time to first and lasting RTW among workers with musculoskeletal disorders more than usual care (HR 1.44, 95% CI 1.15 to 1.82 and HR 1.77, 95% CI 1.37 to 2.29, respectively; both moderate-quality evidence). In studies of workers with musculoskeletal disorders, pain also improved (standardised mean difference (SMD) -0.26, 95% CI -0.47 to -0.06), as well as functional status (SMD -0.33, 95% CI -0.58 to -0.08). In studies of workers with mental health problems, there was a significant improvement in time until first RTW (HR 2.64, 95% CI 1.41 to 4.95), but no considerable reduction in lasting RTW (HR 0.79, 95% CI 0.54 to 1.17). One study of workers with cancer did not find a considerable reduction in lasting RTW (HR 0.88, 95% CI 0.53 to 1.47).In another subgroup analysis, we did not find evidence that offering a workplace intervention in combination with a cognitive behavioural intervention (HR 1.93, 95% CI 1.27 to 2.93) is considerably more effective than offering a workplace intervention alone (HR 1.35, 95% CI 1.01 to 1.82, test for subgroup differences P = 0.17).Workplace interventions did not considerably reduce time until first RTW compared with a clinical intervention in workers with mental health problems in one study (HR 2.65, 95% CI 1.42 to 4.95, very low-quality evidence).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that workplace interventions reduce time to first RTW, high-quality evidence that workplace interventions reduce cumulative duration of sickness absence, very low-quality evidence that workplace interventions reduce time to lasting RTW, and moderate-quality evidence that workplace interventions increase recurrences of sick leave. Overall, the effectiveness of workplace interventions on work disability showed varying results. Workplace interventions reduce time to RTW and improve pain and functional status in workers with musculoskeletal disorders. We found no evidence of a considerable effect of workplace interventions on time to RTW in workers with mental health problems or cancer.We found moderate-quality evidence to support workplace interventions for workers with musculoskeletal disorders. The quality of the evidence on the effectiveness of workplace interventions for workers with mental health problems and cancer is low, and results do not show an effect of workplace interventions for these workers. Future research should expand the range of health conditions evaluated with high-quality studies.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer patients are 1.4 times more likely to be unemployed than healthy people. Therefore it is important to provide cancer patients with programmes to support the return-to-work (RTW) process. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing RTW in cancer patients compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library Issue 3, 2014), MEDLINE (January 1966 to March 2014), EMBASE (January 1947 to March 2014), CINAHL (January 1983 to March, 2014), OSH-ROM and OSH Update (January 1960 to March, 2014), PsycINFO (January 1806 to 25 March 2014), DARE (January 1995 to March, 2014), ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com up to 25 March 2014. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of psycho-educational, vocational, physical, medical or multidisciplinary interventions enhancing RTW in cancer patients. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data. We pooled study results we judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fifteen RCTs including 1835 cancer patients met the inclusion criteria and because of multiple arms studies we included 19 evaluations. We judged six studies to have a high risk of bias and nine to have a low risk of bias. All included studies were conducted in high income countries and most studies were aimed at breast cancer patients (seven trials) or prostate cancer patients (two trials).Two studies involved psycho-educational interventions including patient education and teaching self-care behaviours. Results indicated low quality evidence of similar RTW rates for psycho-educational interventions compared to care as usual (RR 1.09, 95% CI 0.88 to 1.35, n = 260 patients) and low quality evidence that there is no difference in the effect of psycho-educational interventions compared to care as usual on quality of life (standardised mean difference (SMD) 0.05, 95% CI -0.2 to 0.3, n = 260 patients). We did not find any studies on vocational interventions. In one study breast cancer patients were offered a physical training programme. Low quality evidence suggested that physical training was not more effective than care as usual in improving RTW (RR 1.20, 95% CI 0.32 to 4.54, n = 28 patients) or quality of life (SMD -0.37, 95% CI -0.99 to 0.25, n = 41 patients).Seven RCTs assessed the effects of a medical intervention on RTW. In all studies a less radical or functioning conserving medical intervention was compared with a more radical treatment. We found low quality evidence that less radical, functioning conserving approaches had similar RTW rates as more radical treatments (RR 1.04, 95% CI 0.96 to 1.09, n = 1097 patients) and moderate quality evidence of no differences in quality of life outcomes (SMD 0.10, 95% CI -0.04 to 0.23, n = 1028 patients).Five RCTs involved multidisciplinary interventions in which vocational counselling was combined with patient education, patient counselling, and biofeedback-assisted behavioral training or physical exercises. Moderate quality evidence showed that multidisciplinary interventions involving physical, psycho-educational and vocational components led to higher RTW rates than care as usual (RR 1.11, 95% CI 1.03 to 1.16, n = 450 patients). We found no differences in the effect of multidisciplinary interventions compared to care as usual on quality of life outcomes (SMD 0.03, 95% CI -0.20 to 0.25, n = 316 patients).

AUTHORS' CONCLUSIONS

We found moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer.

Municipal return to work management in cancer survivors undergoing cancer treatment: a protocol on a controlled intervention study

Background

Cancer survivors are often left on their own to deal with the challenges of resuming work during or after cancer treatment, mainly due to unclear agreements between stakeholders responsible for occupational rehabilitation. Social inequality exists in cancer risk, survival probability and continues with regard to the chance of being able to return to work.

The aim is to apply an early, individually tailored occupational rehabilitation intervention to cancer survivors in two municipalities parallel with cancer treatment focusing on enhancing readiness for return to work.

Methods/Design

In a controlled trial municipal job consultants use acceptance and commitment therapy dialogue and individual-placement-and-support-inspired tools with cancer survivors to engage them in behaviour changes toward readiness for return to work. The workplace is involved in the return to work process.

Patients referred to surgery, radiotherapy or chemotherapy at the Oncology Department, Aarhus University Hospital, Denmark for the diagnoses; breast, colon-rectal, head and neck, thyroid gland, testicular, ovarian or cervix cancer are eligible for the study. Patients must be residents in the municipalities of Silkeborg or Randers, 18–60 years of age and have a permanent or temporary employment (with at least 6 months left of their contract) at inclusion. Patients, for whom the treating physician considers occupational rehabilitation to be unethical, or who are not reading or talking Danish are excluded. The control group has identical inclusion and exclusion criteria except for municipality of residence.

Return to work is the primary outcome and is indentified in a social transfer payment register. Effect is assessed as relative cumulative incidences within 52 weeks and will be analysed in generalised linear regression models using the pseudo values method. As a secondary outcome; co-morbidity and socio-economic status is analysed as effect modifiers of the intervention effect on return to work.

Discussion

The innovative element of this intervention is the timing of the occupational rehabilitation which is much earlier initiated than usual and the active involvement of the workplace. We anticipate that vulnerable cancer survivors will benefit from this approach and reduce the effects of social inequality on workability.

Trial registration

Current Controlled Trials ISRCTN50753764. Registered August 21^st, 2014.

Efficacy of temporary work modifications on disability related to musculoskeletal pain or depressive symptoms--study protocol for a controlled trial

INTRODUCTION

Previous research suggests that work with a suitable workload may promote health and work retention in people with disability. This study will examine whether temporary work modifications at the early stage of work disability are effective in enhancing return to work (RTW) or staying at work among workers with musculoskeletal or depressive symptoms.

METHODS AND ANALYSIS

A single-centre controlled trial with modified stepped wedge design will be carried out in eight enterprises and their occupational health services (OHSs) in nine cities in Finland. Patients seeking medical advice due to musculoskeletal pain (≥4 on a scale from 0-10) or depressive symptoms (≥1 positive response to 2 screening questions) and fulfilling other inclusion criteria are eligible. The study involves an educational intervention among occupational physicians to enhance the initiation of work modifications. Primary outcomes are sustained RTW (≥4 weeks at work without a new sickness absence (SA)) and the total number of SA days during a 12-month follow-up. Secondary outcomes are intensity of musculoskeletal pain (scale 0-10), pain interference with work or sleep (scale 0-10) and severity of depressive symptoms (Patient Health Questionnaire, PHQ-9), inquired via online questionnaires at baseline and 3, 6, 9 and 12 months after recruitment. Information on SA days will be collected from the medical records of the OHSs over 12 months, before and after recruitment. The findings will give new information about the possibilities of training physicians to initiate work modifications and their effects on RTW in employees with work disability due to musculoskeletal pain or depressive symptoms.

ETHICS AND DISSEMINATION

The Coordinating Ethics Committee of Hospital District of Helsinki and Uusimaa has granted approval for this study. The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN74743666.