Effect of cognitive-behavioural training on job-finding among long-term unemployed people

Results from a Nationwide Evaluation Study of Labor Market-Integrative Health Promotion for the Unemployed: Impact of the JOBS Program Germany

Compared to the employed, the unemployed suffer from poorer health, especially in terms of mental health. At the same time, health promotion rarely reaches unemployed people. The "JOBS Program" is an intervention to promote health and labor market integration and has shown positive effects in the USA and Finland. In this confirmatory study, we investigated whether the JOBS Program achieves similar effects in Germany. We applied a randomized controlled trial to compare an intervention group (IVG) with a waiting control group (WCG) before (T0; N = 94) and shortly after (T1; n = 65) the intervention. Concerning our primary outcomes, the JOBS Program Germany was beneficial: Compared to the WCG, the regression estimated that the IVG had (1) a 2.736 scale point higher level of life satisfaction (p = 0.049), (2) a 0.337 scale point higher level of general health (p = 0.025), and (3) a 14.524 scale point higher level of mental well-being (p = 0.004). Although not statistically significant, job search-specific self-efficacy also appeared to be positively associated with the intervention. This study provides evidence of the effectiveness of JOBS Program on the abovementioned outcomes, including for older and long-term unemployed people, supporting the benefits of regular implementation of this program for a wide range of unemployed people in Germany.

The Effectiveness of Health-Oriented Interventions and Health Promotion for Unemployed People-A Meta-Analysis

Background: Unemployment is known to have negative effects on mental and physical health. Yet, the effectiveness of interventions aimed at improving the health of unemployed people is unclear. Methods: We conducted a random-effects meta-analysis of extant intervention studies with at least two measurement points and a control group. A literature search in PubMed, Scopus, and PsycINFO in December 2021 identified 34 eligible primary studies with 36 independent samples. Results: For mental health, the average meta-analytic effect sizes for the comparison of the intervention group and the control group were significant and of small size after the intervention, d = 0.22; 95% CI [0.08, 0.36], as well as at follow-up, d = 0.11; 95% CI [0.07, 0.16]. Effects on self-assessed physical health status were small and marginally significant (p = 0.10) after the intervention: d = 0.09; 95% CI [-0.02, 0.20], and insignificant at follow-up. However, when job search training was not part of the intervention program (i.e., all available resources were used solely for health promotion), the average effect size for physical health was significant after the intervention, d = 0.17; 95% CI [0.07, 0.27]. Furthermore, the effects of physical activity promotion were significant and of small-to-medium size after the intervention, leading to increased levels of activity, d = 0.30; 95% CI [0.13, 0.47]. Conclusions: Population-based health promotion programs are recommended because even measures with small effect sizes can actually improve the health of a large group of unemployed people.

Mental health and unemployment: A systematic review and meta-analysis of interventions to improve depression and anxiety outcomes

BACKGROUND

Unemployment is associated with substantially greater depression and anxiety, constituting a considerable public health concern. The current review provides the most comprehensive synthesis to date, and first meta-analysis, of controlled intervention trials aimed at improving depression and anxiety outcomes during unemployment.

METHODS

Searches were conducted within PsycInfo, Cochrane Central, PubMed and Embase from their inception to September 2022. Included studies conducted controlled trials of interventions focused on improving mental health within unemployed samples, and reported on validated measures of depression, anxiety, or distress (mixed depression and anxiety). Narrative syntheses and random effects meta-analyses were conducted among prevention- and treatment-level interventions for each outcome.

RESULTS

A total of 39 articles reporting on 33 studies were included for review (sample sizes ranging from 21 to 1801). Both prevention and treatment interventions tended to be effective overall, with treatment interventions producing larger effect sizes than prevention interventions. The clearest evidence for particular intervention approaches emerged for prevention-level Cognitive Therapy/CBT, followed by prevention-level work-related interventions, although neither produced entirely consistent effects.

LIMITATIONS

Risk of bias was generally high across studies. Low numbers of studies within subgroups precluded any comparisons between long-term and short-term unemployment, limited comparisons among treatment studies, and reduced the power of meta-analyses.

CONCLUSIONS

Both prevention- and treatment-level mental health-focused interventions have merit for reducing symptoms of anxiety and depression among those experiencing unemployment. Cognitive Therapy/CBT and work-related interventions hold the most robust evidence base, which can inform both prevention and treatment strategies implemented by clinicians, employment services providers, and governments.

Systematic realist synthesis of health-related and lifestyle interventions designed to decrease overweight, obesity and unemployment in adults

Background

Obesity and unemployment are complex social and health issues with underlying causes that are interconnected. While a clear link has been established, there is lack of evidence on the underlying causal pathways and how health-related interventions could reduce obesity and unemployment using a holistic approach.

Objectives

The aim of this realist synthesis was to identify the common strategies used by health-related interventions to reduce obesity, overweight and unemployment and to determine for whom and under what circumstances these interventions were successful or unsuccessful and why.

Methods

A realist synthesis approach was used. Systematic literature searches were conducted in Cochrane library, Medline, SocIndex, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PsychInfo. The evidence from included studies were synthesised into Context-Mechanism-Outcome configurations (CMOcs) to better understand when and how programmes work, for which participants and to refine the final programme theory.

Results

A total of 83 articles met the inclusion criteria. 8 CMOcs elucidating the contexts of the health-related interventions, underlying mechanisms and outcomes were identified. Interventions that were tailored to the target population using multiple strategies, addressing different aspects of individual and external environments led to positive outcomes for reemployment and reduction of obesity.

Conclusion

This realist synthesis presents a broad array of contexts, mechanisms underlying the success of health-related interventions to reduce obesity and unemployment. It provides novel insights and key factors that influence the success of such interventions and highlights a need for participatory and holistic approaches to maximise the effectiveness of programmes designed to reduce obesity and unemployment.

Trial registration

PROSPERO 2020 CRD42020219897.

Returning to work after fatigue treatment and counseling in HIV/AIDS

BACKGROUND

Employment rates for people with HIV/AIDS are low, compared to the general population. One widespread barrier is fatigue, accompanied by daytime sleepiness and a lack of stamina. Previous pharmacological studies have demonstrated improvement of fatigue-related symptoms without affecting work-related goal attainmentOBJECTIVE:In this pilot study, we sought to determine whether a pharmacologic-behavioral two-phase combined approach could facilitate returning to work.

METHODS

HIV+ participants with fatigue were treated with armodafinil. If energy improved, 8 sessions of biweekly manualized Behavioral Activation (BA) counseling were added to medication maintenance. Outcome was assessed on a 3-point scale along with clinician and self-ratings.

RESULTS

Of the 46 participants enrolled in BA, 15 (33%) did not complete all 8 sessions: 6 got jobs so they no longer needed counseling; 4 did not like BA, and 5 dropped out for reasons such as moving away or substance use relapse. Of the 46, 29 (63%) attained their vocational goal and showed significant changes on self-report scales.

CONCLUSIONS

Our integrated treatment including armodafinil plus BA counseling significantly increased the success of achieving work-related goals. The two-phase medication plus counseling program was well-tolerated by participants and the manualized BA counseling was readily applied by counselors without advanced mental health training, making the method potentially feasible in community settings.

Health promotion and prevention among the unemployed: a systematic review

The interactions between unemployment and health create a need for specific interventions for health promotion and prevention. This overview provides information on how health promotion for the unemployed has been approached with an analysis of controlled intervention studies between 1996 and 2016. The literature search consulted 11 international databases in medicine, social sciences and psychology. A total of 30 health interventions for the unemployed were identified, with 43 articles that included the effects of intervention. A controlled-study design was used in 14 studies. The health promotion measures were generally based on individual counselling, case management, training or group services. The overview demonstrates the breadth of variation in target groups and types of measures. Their result indicators for health and integration into the labor market vary substantially, as do the employment promotion effects. There is evidence of improved health and labor market integration for established approaches like the JOBS Program and JobFit. Effects are rather moderate or low in magnitude and the effect mechanisms often remain unclear. Effects weaken over time. While success is more common in the areas of health, physical activity, nutrition and stress relief, there was no impact on smoking behavior. A significant evolution can be observed in the quality and quantity of health promotion for the unemployed over time. There is a need for further research on the effectiveness and sustainability of interventions. Intervention strategies should be developed that take account of the diversity of the unemployed and their different needs.

Health-improving interventions for obtaining employment in unemployed job seekers

BACKGROUND

Unemployment is associated with decreased health which may be a reason or a consequence of becoming unemployed. Decreased health can inhibit re-employment.

OBJECTIVES

To assess the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers.

SEARCH METHODS

We searched (3 May 2018, updated 13 August 2019) the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, PsycINFO, CINAHL, SocINDEX, OSH Update, ClinicalTrials.gov, the WHO trials portal, and also reference lists of included studies and selected reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers. The primary outcome was re-employment reported as the number or percentage of participants who obtained employment. Our secondary outcomes were health and work ability.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted outcome data, and assessed risk of bias. We pooled study results with random-effect models and reported risk ratios (RRs) with 95% confidence intervals (CIs) and assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 15 randomised controlled trials (16 interventions) with a total of 6397 unemployed participants. Eight studies evaluated therapeutic interventions such as cognitive behavioural therapy, physical exercise, and health-related advice and counselling and, in seven studies, interventions were combined using therapeutic methods and job-search training. Therapeutic interventions Therapeutic interventions compared to no intervention may increase employment at an average of 11 months follow-up but the evidence is very uncertain (RR = 1.41, 95% CI 1.07 to 1.87, n = 1142, 8 studies with 9 interventions, I² = 52%, very low-quality evidence). There is probably no difference in the effects of therapeutic interventions compared to no intervention on mental health (SMD 0.12, 95% CI -0.06 to 0.29, n = 530, 2 studies, low-quality evidence) and on general health (SMD 0.19, 95% CI -0.04 to 0.41, n = 318, 1 study, moderate-quality evidence). Combined interventions Combined interventions probably increase employment slightly compared to no intervention at an average of 10 months follow-up (RR 1.12, 95% CI 1.06 to 1.20, n = 4101, 6 studies, I² = 7%). There were no studies that measured work-ability, adverse events, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Interventions combining therapeutic methods and job-search training probably have a small beneficial effect in increasing employment. Therapeutic interventions may have an effect on re-employment, but we are very uncertain. Therapeutic interventions may not improve health in unemployed job seekers. Large high-quality RCTs targeting short-term or long-term unemployed people are needed to increase the quality of the evidence. A cost-effectiveness assessment is needed of the small beneficial effects.

Study protocol: A multisite trial of Work-Related Cognitive behavioral therapy for unemployed persons with social anxiety

This paper provides a methodological description of a multi-site, randomized controlled trial (RCT) of a cognitive-behavioral intervention for enhancing employment success among unemployed persons whose employment efforts have been undermined by social anxiety disorder (SAD). SAD is a common and impairing condition, with negative impacts on occupational functioning. In response to these documented employment-related impairments, in a previous project, we produced and tested an eight-session work-related group cognitive-behavioral therapy provided alongside vocational services as usual (WCBT + VSAU). WCBT is delivered by vocational service professionals and is designed in a context and style that overcomes accessibility and stigma-related obstacles with special focus on employment-related targets. Our previous project found that WCBT + VSAU significantly improved social anxiety, depression, and a range of employment-related outcomes compared to a control group of socially anxious job-seekers who received vocational services as usual without WCBT (VSAU-alone). Participants in this study were all homeless, primarily African American job-seekers with high levels of psychiatric comorbidity and limited education and employment histories. The present, two-region study addresses whether WCBT + VSAU enhances job placement, job retention and mental health outcomes in a larger sample assessed over an extended follow-up period. In addition, this trial evaluates whether the effects of WCBT + VSAU generalize to a new population of urban-based, racially diverse job-seekers with vocational and educational histories that differ from our original sample. This study also investigates the system-effects of WCBT + VSAU in a new site that will be informative for broad implementation of WCBT + VSAU. Finally, this project involves a refined, technology-assisted form of WCBT + VSAU designed to be delivered more easily by vocational services professionals.

Associations with Wellbeing and Medication Adherence in Young Adults Receiving Kidney Replacement Therapy

BACKGROUND AND OBJECTIVES

Young adults receiving kidney replacement therapy (KRT) have impaired quality of life and may exhibit low medication adherence. We tested the hypothesis that wellbeing and medication adherence are associated with psychosocial factors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a cross-sectional online survey for young adults on KRT. Additional clinical information was obtained from the UK Renal Registry. We compared outcomes by treatment modality using age- and sex-adjusted regression models, having applied survey weights to account for response bias by sex, ethnicity, and socioeconomic status. We used multivariable linear regression to examine psychosocial associations with scores on the Warwick-Edinburgh Mental Wellbeing Scale and the eight-item Morisky Medication Adherence Scale.

RESULTS

We recruited 976 young adults and 64% responded to the survey; 417 (71%) with transplants and 173 (29%) on dialysis. Wellbeing was positively associated with extraversion, openness, independence, and social support, and negatively associated with neuroticism, negative body image, stigma, psychologic morbidity, and dialysis. Higher medication adherence was associated with living with parents, conscientiousness, physician access satisfaction, patient activation, age, and male sex, and lower adherence was associated with comorbidity, dialysis, education, ethnicity, and psychologic morbidity.

CONCLUSIONS

Wellbeing and medication adherence were both associated with psychologic morbidity in young adults. Dialysis treatment is associated with poorer wellbeing and medication adherence.

EEPIC - Enhancing Employability through Positive Interventions for improving Career potential: the impact of a high support career guidance intervention on the wellbeing, hopefulness, self-efficacy and employability of the long-term unemployed - a study protocol for a randomised controlled trial

Background

Labour market policy (LMP) and its implementation have undergone rapid change internationally in the last three decades with a continued trend towards active LMP. In Ireland however, this shift has been more recent with ongoing reforms since 2012 and a concomitant move toward active labour market ‘work-first’ policy design (i.e. whereby unemployed people are compulsorily required to work in return for their social welfare benefits). Labour market policies vary from those that require this compulsory approach to those which enable the unemployed to move towards sustainable quality work in the labour market through upskilling (human capital approach). Despite this, however, long-term unemployment—a major cause of poverty and social exclusion—remains high, while current employment support approaches aimed at sustainable re-employment are, arguably, unevaluated and under examined. This study examines the effectiveness of a new high support career guidance intervention in terms of its impact on aspects of wellbeing, perceived employability and enhancing career sustainability.

Method

The study involves a single-centre randomised, controlled, partially blinded trial. A total of 140 long-term unemployed job-seekers from a disadvantaged urban area will be randomly assigned to two groups: (1) an intervention group; and (2) a ‘service as usual’ group. Each group will be followed up immediately post intervention and six months later. The primary outcome is wellbeing at post intervention and at six-month follow-up. The secondary outcome is perceived employability, which includes a number of different facets including self-esteem, hopefulness, resilience and career self-efficacy.

Discussion

The study aims to assess the changes in, for example, psychological wellbeing, career efficacy and hopefulness, that occur as a result of participation in a high support intervention vs routinely available support. The results will help to inform policy and practice by indicating whether a therapeutic approach to job-seeking support is more effective for long-term unemployed job-seekers than routinely available (and less therapeutic) support. The findings will also be important in understanding what works and for whom with regard to potentially undoing the negative psychological impacts of unemployment, building psychological capital and employability within the individual, and developing career trajectories leading to more sustainable employment.

Trial registration

ISRCTN registry, ISRCTN16801028. Registered on 9 February 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2485-y) contains supplementary material, which is available to authorized users.

Contextual evaluation of social adversity in the management of depressive disorder

Contextual rating of social adversity has its origins in the work of George Brown and colleagues (Brown & Harris, 1978). This review evaluates its strengths and weaknesses in rating the effects of social adversity on depressive disorder. We write from the perspective of its usefulness for clinical and training purposes both to the consultant psychiatrist and to the community mental health team working in general adult psychiatry.

Full metal jacket or the emperor's new clothes?

Launched with little more than a whimper during the Labour Party Conference the much vaunted National Service Framework for Mental Health (NSF–MH) outlines the Government's ‘ambitious agenda’ for mental health services (Department of Health, 1999a). The official driving force has been the desire to deliver a quality service throughout the whole NHS via clinical governance and underpinned by professional self-regulation. Developed following widespread consultation and with the advice of the External Reference Group (although some of this advice was clearly disregarded), the NSF–MH provides a series of seven core standards with examples of good practice. Although developed with general psychiatry and severe mental illness in mind, the NSF is not quite the ‘National Schizophrenia Framework’ that some envisaged, since it also acknowledges the needs of young people and the influence of developmental factors on adult mental health. The NSF–MH sets standards in five areas: mental health promotion, primary care and access to services, services for the severely mentally ill, caring about carers and preventing suicide. It is only the second to be published (the other being for coronary care) which is hopefully a reflection of the ‘priority’ once more being given to mental health. However, the near-simultaneous appointment of a cancer ‘tsar’ suggests that ‘priority’ is a readily used and easily diluted term.

Defining a Brief Intervention for the Promotion of Psychological Well-being among Unemployed Individuals through Expert Consensus

BACKGROUND

Epidemiologic evidence highlights the harmful consequences of unemployment on health and well-being. This emphasizes the need to design low-cost interventions to prevent the adverse mental health effects of unemployment. The main aim of this study was to create expert-consensus regarding development and implementation of a brief, sustainable, and effective intervention program for promoting mental health among unemployed.

METHODS

The Delphi technique entailed a selected panel of 75 experts from various relevant professional backgrounds. Panel members were asked to state their level of agreement (5-point Likert scale) regarding (a) required characteristics for an effective mental health intervention for unemployed people and (b) key variables for assessing the effectiveness of that intervention. Consensus was obtained throughout two rounds of data collection through e-mail contact, with structured questionnaires. Items of the questionnaire were based on literature reviews about community-based interventions for unemployed individuals.

RESULTS

Overall, 46 experts collaborated with the Delphi process (final participation rate: 61.3%). Based on a review of the literature, 185 items were identified and grouped into two broad categories (set of characteristics of the intervention and set of variables for effectiveness assessment), aggregating a total of 11 dimensions. The two Delphi rounds resulted in the selection of 35 characteristic items for the intervention program and 54 variables for its effectiveness assessment. Brief group interventions were considered to be effective and sustainable for mental health promotion in unemployment conditions if targeting mental health literacy, training interpersonal skills, and job-search skills.

CONCLUSION

As agreed by the panel of experts, a brief, sustainable and effective intervention can be developed and implemented by accounting for unemployed capacity-building for mental health self-care and adequate job-searching attitudes and skills. These results should be further implemented in community and multisector-based standardized interventions, targeting mental health among unemployed people, ensuring adequate conditions for its effectiveness assessment.

Interventions to mitigate the effects of poverty and inequality on mental health

PURPOSE

To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health.

METHODS

Systematic reviews, controlled trials and realist evaluations of the last 10 years are reviewed, without age or geographical restrictions.

RESULTS

Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted.

CONCLUSIONS

The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate a cross-sectoral approach, and to form partnerships between different government departments, civic society organisations and other stakeholders. This approach is referred to as Mental Health in All Policies and it can be applied to all public policy levels from local policies to supranational.

Interventions to reduce the impact of unemployment and economic hardship on mental health in the general population: a systematic review

BACKGROUND

Job loss, debt and financial difficulties are associated with increased risk of mental illness and suicide in the general population. Interventions targeting people in debt or unemployed might help reduce these effects.

METHOD

We searched MEDLINE, Embase, The Cochrane Library, Web of Science, and PsycINFO (January 2016) for randomized controlled trials (RCTs) of interventions to reduce the effects of unemployment and debt on mental health in general population samples. We assessed papers for inclusion, extracted data and assessed risk of bias.

RESULTS

Eleven RCTs (n = 5303 participants) met the inclusion criteria. All recruited participants were unemployed. Five RCTs assessed 'job-club' interventions, two cognitive behaviour therapy (CBT) and a single RCT assessed each of emotional competency training, expressive writing, guided imagery and debt advice. All studies were at high risk of bias. 'Job club' interventions led to improvements in levels of depression up to 2 years post-intervention; effects were strongest among those at increased risk of depression (improvements of up to 0.2-0.3 s.d. in depression scores). There was mixed evidence for effectiveness of group CBT on symptoms of depression. An RCT of debt advice found no effect but had poor uptake. Single trials of three other interventions showed no evidence of benefit.

CONCLUSIONS

'Job-club' interventions may be effective in reducing depressive symptoms in unemployed people, particularly those at high risk of depression. Evidence for CBT-type interventions is mixed; further trials are needed. However the studies are old and at high risk of bias. Future intervention studies should follow CONSORT guidelines and address issues of poor uptake.

Effective communication in mental health nurses: Did social support save the psychiatric nurse?

A randomised controlled trial was conducted to test the effectiveness of a social support-based intervention against a feedback-only condition. Fifty-three mental health nurses were randomly allocated and assessed on a range of measures of the stress process. Stressors were measured by the DCL Stress scale, mediating variables by the Rosenberg Self-Esteem scale, the Pearlin Mastery scale and the Significant Others scale and stress outcomes by the General Health Questionnaire and the Maslach Burnout Inventory. Following a successful pilot of the social support package, it was hypothesised that the social support intervention would be more effective in reducing stress and burnout in mental health nurses. Participants in both groups were assessed prior to randomisation, post-treatment and at six months follow-up. Attrition rates were similar in both conditions, at around 30%. The social support groups were run for five consecutive weeks for two hours. In all, three separate groups were conducted by two facilitators. The members of the feedback-only group received detailed written feedback on their stress questionnaires, as well as a small stress management booklet developed by two of the authors. Results of the study show no benefits for participants of the social support groups on the study's dependent variables and indeed there was a trend for the feedback-only group to do slightly better on some of the measures. The reasons for this negative outcome are discussed and suggestions are made for future studies. Methodological difficulties are pointed out with studies that attempt to reduce staff stress.

An Agenda for Unemployment Research: A Challenge for Public Health

Unemployment figures are high worldwide, and this should be a challenge for both researchers and politicians. Public health research has a tradition of descriptive studies among the unemployed at the individual level and has to a limited extent been engaged in interventive and preventive trials to study the effect of different measures to counter unemployment. The article gives a brief review of the development of postwar unemployment research and proposes an agenda for unemployment research within public health for the coming years.

Maintaining Wellbeing during Unemployment

A survey of 371 unemployed people in South East Queensland explored whether deprivation of the latent benefits of employment was able to predict psychological distress after controlling for other key correlates. A standard multiple regression found that the latent benefits (timestructure, social contact, collective purpose, enforced activity, and status) accounted for a significant 13 per cent of the variance in psychological distress, with time structure being the most important unique predictor. However, after controlling for self-esteem, positive affect (PA), negative affect (NA), satisfaction with employment status, employment commitment, and financial strain, the latent benefits did not significantly add to the prediction of distress. The results are discussed in terms of their practical implications for career development.

The Effects of Emotional Competences Training among Unemployed Adults: A Longitudinal Study

BACKGROUND

The present study aimed at analyzing whether training in emotional competences (EC) would increase the level of perceived EC among unemployed adults, whether the unemployment duration would moderate the effects of the training and whether the changes in EC would predict changes in the levels of perceived stress, somatic complaints, mental health, and mood states.

METHODS

Seventy-five participants were randomly allocated to an EC training program, or a control group. Following a controlled experimental design, the participants completed all the measures prior to the intervention (T1), one month later (T2) and six months after the first data collection (T3).

RESULTS

The results showed that change in EC after the training depended on the duration of unemployment. The difference between the experimental and control groups in EC after the training was significant when the participants had been unemployed for less time. In addition, the results indicated that changes in EC were found to be significant predictors of changes in perceived stress, mental health, somatic complaints, and vigor and confusion (mood dimensions) six months after the intervention.

CONCLUSION

The data suggest that unemployment duration plays a crucial role in determining the range and intensity of intervention effects.

Evaluating an online support package delivered within a disability unemployment service: study protocol for a randomised controlled feasibility study

Background

Mental health problems such as anxiety and depression are known to be higher in those who are unemployed. Cognitive behavioural therapy (CBT) is a recognised support for people with such problems and can improve the ability of people to get back to work.

Methods/design

Participants with symptoms of low mood will be recruited from the disability employment service, Remploy. Participants will receive either immediate or delayed access to an online CBT-based life skills intervention, the “Living Life” package. The primary end point will be at 3 months when the delayed group will be offered the intervention. This feasibility study will test the trial design and assess recruitment, retention, acceptability and adherence, as well as providing efficacy data.

Discussion

The study will inform the design and sample size for a future full randomised controlled trial (RCT) which will be carried out to determine the effectiveness of the online package in improving mood and employment status.

Trial registration

Current Controlled Trials ISRCTN10316077.

Gains in employment status following antidepressant medication or cognitive therapy for depression

BACKGROUND

Depression can adversely affect employment status.

AIMS

To examine whether there is a relative advantage of cognitive therapy or antidepressant medication in improving employment status following treatment, using data from a previously reported trial.

METHOD

Random assignment to cognitive therapy (n = 48) or the selective serotonin reuptake inhibitor paroxetine (n = 93) for 4 months; treatment responders were followed for up to 24 months. Differential effects of treatment on employment status were examined.

RESULTS

At the end of 28 months, cognitive therapy led to higher rates of full-time employment (88.9%) than did antidepressant medication among treatment responders (70.8%), χ(2) 1 = 5.78, P = 0.02, odds ratio (OR) = 5.66, 95% CI 1.16-27.69. In the shorter-term, the main effect of treatment on employment status was not significant following acute treatment (χ(2) 1 = 1.74, P = 0.19, OR = 1.77, 95% CI 0.75-4.17); however, we observed a site×treatment interaction (χ(2) 1 = 6.87, P = 0.009) whereby cognitive therapy led to a higher rate of full-time employment at one site but not at the other.

CONCLUSIONS

Cognitive therapy may produce greater improvements in employment v. medication, particularly over the longer term.

Advancing the accessibility of psychotherapy: learning from our international colleagues

Although the Affordable Care Act has theoretically made access to mental health care possible for all patients, the United States continues to lag behind other countries with respect to the provision of psychotherapeutic treatments. In the United Kingdom, for example, substantial resources have been committed to increase the availability of effective psychotherapies, particularly for depression and anxiety disorders. This development required a significant deployment of resources, with more than one billion dollars committed over the course of 7 years (2008-2015). Over 6,000 therapists have been trained and are currently being deployed in specialized local services to treat patients with depression and anxiety. A second phase of the initiative aims to bring psychotherapeutic treatment to patients with schizophrenia, bipolar disorder, and borderline personality disorder. Psychotherapy advocates in the United States may be more successful in advocating for such treatments by using similar methods to influence legislators and insurers.

Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors

BACKGROUND

A growing body of research evidence from countries around the world indicates that economic recession is associated with increases in suicide, particularly in males of working age.

AIMS

To explore contributory and ameliorating factors associated with economic recession and suicide and thereby stimulate further research in this area and encourage policy makers to consider how best to reduce the impact of recession on mental health and suicidal behaviour.

METHOD

We conducted a selective review of the worldwide literature focusing on possible risk factors, mechanisms and preventative strategies for suicidal behaviour linked to economic recession.

RESULTS

A model of how recession might affect suicide rates is presented. A major and often prolonged effect of recession is on unemployment and job insecurity. Other important effects include those exerted by financial loss, bankruptcy and home repossession. It is proposed these factors may lead directly or indirectly to mental health problems such as depression, anxiety and binge drinking and then to suicidal behaviour. Countries with active labour market programmes and sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job-search initiatives for the unemployed. Other measures likely to help include targeted interventions for unemployed people, membership of social organisations and responsible media reporting. Good primary care and mental health services are needed to cope with increased demand in times of economic recession but some governments have in fact reduced healthcare spending as an austerity measure.

CONCLUSION

The research evidence linking recession, unemployment and suicide is substantial, but the evidence for the other mechanisms we have investigated is much more tentative. We describe the limitations of the existing body of research as well as make suggestions for future research into the effects of economic recession on suicidal behaviour.

Does provision of targeted health care for the unemployed enhance re-employment?

Background

There is increasing pressure to develop services to enhance the health of the workforce on the periphery of the labour market. Health promotion among unemployed people may improve their health but also to increase their employability. We tested whether re-employment can be enhanced with a health care intervention targeted at the unemployed.

Methods

A 3-year follow-up, controlled design was used. The data were collected among unemployed people (n = 539) participating in active labour market policy measures. The baseline survey included established habitually used health questionnaires. The intervention consisted of three health check-ups and on-demand health services. Logistic regression analyses were used to obtain the odds ratios of the intervention group versus control group for being re-employed at follow-up. Health-related differences in the re-employment effects of the intervention were assessed through the significance of the interaction in the regression analyses.

Results

The intervention did not serve to improve re-employment: at follow-up 50% of both the intervention group and the control group were at work. In further analyses, the odds ratios showed that the intervention tended to improve re-employment among participants in good health, whereas an opposite tendency was seen among those with poor health. The differences, however, were statistically non-significant.

Conclusion

The experimental health service did not show any beneficial effects on re-employment. Nevertheless, rather than considering any particular health care as unnecessary and ineffective, we would like to stress the complexity of providing health services to match the diversity of the unemployed.

Workplace effectiveness and psychotherapy for mental, substance abuse, and subsyndromal conditions

While it is known that psychiatric illness and subclinical psychiatric illness can be very disabling, their impact on workers' productivity has been little appreciated or appropriately addressed. Complex variables are involved in fashioning an appropriate policy to ameliorate the impact of mental illness on productivity including the identification of effective treatments and potential negative effects of controlling patients' access to them. The cost-effectiveness of such treatments is considered from the differing perspectives and goals of the various stakeholders involved, including employers, insurers, and workers with psychiatric illness. Depression in workers leads to significant absenteeism, "presenteeism" (diminished capacity due to illness while still present at work), and significantly increased medical expenses in addition to the costs of psychiatric care. In addition to the specific usefulness of psychotropic medication, there are a variety of studies on the cost-effectiveness of different psychotherapeutic treatments that improve health and productivity in psychiatrically ill workers. Research indicates the usefulness of approaches including employee assistance programs, specialized cognitive-behavioral treatments, and brief and longer term psychodynamic interventions. It is clear that substance abuse disorders and especially depression and subsyndromal depression have a profound negative effect on work productivity and increases in medical visits and expenses. The current system of mental health care suffers from ignorance of the negative effects of psychiatric illness in workers, from a lack of subtle awareness of which treatments are most appropriate for which diagnoses and from the reluctance by payers to invest in them. Access to evidence-based appropriate treatment can improve the negative impact on productivity as well as workers' health. This article considers these issues and argues for a role of psychotherapy in the treatment of mental illness and substance abuse from the perspective of worker productivity.

Addressing mental health and reemployment for unemployed Australians through psychological interventions: An applied study

Few studies have examined the effectiveness of interventions to improve mental health in the unemployed. Current evidence points to interventions improving mental health but having little, if any, impact on reemployment. In the Australian context, psychological services continue to be delivered yet little is known about their effectiveness. This study examined the effectiveness of psychological services for 783 unemployed individuals. It was hypothesized that psychological intervention would improve the symptoms of depression, anxiety, stress and general psychological distress; that individual one-on-one interventions would be more effective than other interventions; and that improvements in mental health would be associated with reemployment. Results highlighted that psychological intervention was effective at improving mental health; that tailored individual interventions were not significantly more effective than other types of interventions and that improvements in depression, anxiety and stress were associated with reemployment.

An evaluation of the choices for well-being project

The relationship between mental health, self-esteem and unemployment is well established. Emerging research suggests that interventions such as Cognitive Behavioural Therapy (CBT) can counter the negative effects of unemployment and may improve re-employment. This study evaluated the effectiveness of a manual-based programme, which combines CBT with job skills training, in improving the psychological health and job- seeking skills of unemployed individuals within the UK. One hundred and nine unemployed individuals, suffering mild to moderate mental health problems, were referred to the programme. Of these, 47 completed the programme and 32 attended follow-up. The impact of the manualised course was evaluated using a randomised control trial with a waiting list control. On completion of the programme, participants showed improvements in mental health, self- esteem and job-search self-efficacy as well as a reduction in the occurrence of negative automatic thoughts. Twenty participants gained employment and improvements persisted at follow-up. Considering the initial levels of psychological distress and mental health problems among the unemployed sample, the need for adequate service provision for the unemployed is recommended.

Predictors of functional disability in disability welfare claimants

BACKGROUND

People unemployed and claiming welfare due to poor health are by definition functionally disabled. Understanding the factors associated with such disability is crucial in the development of biopsychosocial formulations and associated occupational rehabilitation.

METHOD

A cross-sectional design in a sample of claimants (n = 4,119) of health-related welfare, unemployed due to mental or physical health problems. Participants provided socio-demographic information and completed validated measures of psychological distress, self-efficacy and disability. Hierarchical multiple regression analyses then tested which psychological and socio-demographic factors were associated with disability.

RESULTS

Despite equal rates of functional disability across health condition groups, differing variables were associated with disability for mental and physical health conditions. Psychological distress was the strongest predictor of disability across all health conditions. For physical conditions, lack of previous employment was the only additional variable associated with current disability and for mental health conditions age and self-efficacy were additional factors.

CONCLUSION

Results are discussed in terms of biopsychosocial formulations of health-related unemployment, the potential mechanisms by which psychological distress can influence disability, the methodological limitations of cross sectional regression analyses and the implications for condition-specific occupational rehabilitation.

Health-related and social factors predicting non-reemployment amongst newly unemployed

Background

Many researchers have examined the effect that mental health has on reemployment opportunities amongst the unemployed, but the results are inconclusive. Our aim in this study is to investigate the effects that different aspects of mental and physical health, as well as socio-demographic, social, and economic factors, have on reemployment.

Methods

A questionnaire was administered to 1,000 and answered by 502 newly registered unemployed Swedes, who were followed for one year using data from the Swedish National Labour Market Board. The differences between those reemployed and those not reemployed was analysed using stepwise logistic regression.

Results

General mental ill health amongst unemployed individuals measured by the General Health Questionnaire scale was associated with lower levels of reemployment after one year. This effect could not be explained by any of the scales measuring specific aspects of mental disease such as health-related level of function, rate of depression, burnout, or alcohol misuse. Instead being above 45, low control over one’s financial situation, being an immigrant, and visiting a physician during the last three months were better predictors of failure to be reemployed.

Conclusion

There are theoretical reasons to assume that psychological distress leads to a decreased reemployment rate amongst the unemployed. The results of this study partly endorse this hypothesis empirically, showing that general subjective mental distress decreases the rate of reemployment amongst newly unemployed individuals, although this effect was mediated by social and economic factors. Indicators of psychiatric disease had no significant effect on reemployment. The results of this study lead us to suggest the early introduction of financial counselling, psychological support, and other interventions for groups with lower reemployment rates.

Overcoming perceived barriers to employment among people with arthritis

Work disability is a major problem for people with arthritis. The INTO WORK Personal Development (IWPD) programme aims to prevent work disability by addressing the internal and external barriers faced by people with arthritis seeking to fulfil their employment potential. The effectiveness of the programme was examined in a pretest-post-test study with an intervention group (n = 37) and a comparison control group (n = 42). Data were collected through self-administered questionnaires and focus groups. Significant decreases on anxiety (p = .0002), depression (p = .009) and negative mood (p = .029), and significant improvements on positive mood (p = .011), self-esteem (p = .002) and satisfaction with life (p = .010) were found for the intervention group only. The IWPD programme appears to promote self-determination, psychological well-being and strategies for overcoming perceived barriers to employment among people with arthritis.

Actions to alleviate the mental health impact of the economic crisis

The current global economic crisis is expected to produce adverse mental health effects that may increase suicide and alcohol-related death rates in affected countries. In nations with greater social safety nets, the health impacts of the economic downturn may be less pronounced. Research indicates that the mental health impact of the economic crisis can be offset by various policy measures. This paper aims to outline how countries can safeguard and support mental health in times of economic downturn. It indicates that good mental health cannot be achieved by the health sector alone. The determinants of mental health often lie outside of the remits of the health system, and all sectors of society have to be involved in the promotion of mental health. Accessible and responsive primary care services support people at risk and can prevent mental health consequences. Any austerity measures imposed on mental health services need to be geared to support the modernization of mental health care provision. Social welfare supports and active labour market programmes aiming at helping people retain or re-gain jobs can counteract the mental health effects of the economic crisis. Family support programmes can also make a difference. Alcohol pricing and restrictions of alcohol availability reduce alcohol harms and save lives. Support to tackle unmanageable debt will also help to reduce the mental health impact of the crisis. While the current economic crisis may have a major impact on mental health and increase mortality due to suicides and alcohol-related disorders, it is also a window of opportunity to reform mental health care and promote a mentally healthy lifestyle.

Rethinking Psychological Mindedness: Metacognition, Self-reflection, and Insight

Psychological mindedness (PM) has long been considered to be an important mediator of therapy outcome. However, to date, definitions of PM have been typified by linguistic imprecision and lack of conceptual clarity. Further, most definitions and measures of PM have approached the task from a psychodynamic perspective, thus limiting the use of this construct by clinicians and researchers from other theoretical perspectives. In this paper, previous definitions and self-report measures are reviewed and a new definition proposed. It is argued that PM is best conceptualised as a form of metacognition: a predisposition to engage in metacognitive acts of inquiry into how and why people behave, think, and feel in the way that they do. A new model, based on this definition, suggests that PM may be assessed by measuring individuals' metacognitive processes of self-reflection and insight, circumventing many of the problems associated with previous self-report measures of PM. Research into individual differences in propensity for PM, self-reflection, and insight may well provide the clinician with additional tools with which to facilitate purposeful, directed change in both clinical and nonclinical populations.

The case for randomized controlled trials to assess the impact of clinical information systems

There is a persistent view of a significant minority in the medical informatics community that the randomized controlled trial (RCT) has a limited role to play in evaluating clinical information systems. A common reason voiced by skeptics is that these systems are fundamentally different from drug interventions, so the RCT is irrelevant. There is an urgent need to promote the use of RCTs, given the shift to evidence-based policy and the need to demonstrate cost-effectiveness of these systems. The authors suggest returning to first principles and argue that what is required is clarity about how to match methods to evaluation questions. The authors address common concerns about RCTs, and the extent to which they are fallacious, and also discuss the challenges of conducting RCTs in informatics and alternative study designs when randomized trials are infeasible. While neither a perfect nor universal evaluation method, RCTs form an important part of an evaluator's toolkit.

Can a ‘return-to-work’ agenda fit within the theory and practice of CBT for depression and anxiety disorders?

Helping service users to return to work has emerged as a key therapeutic objective of the Improving Access to Psychological Therapies (IAPT) initiative. IAPT programmes implement National Institute for Health and Clinical Excellence (NICE) guidelines, especially cognitive behaviour therapy (CBT), for people suffering from anxiety and depression. However, relatively little research has been conducted to date into whether, or how, cognitive behavioural interventions can help individuals return to work. This paper reviews literature and research into CBT and occupational outcomes and considers whether a return-to-work agenda may jeopardize the therapeutic alliance which is suggested to be necessary for effective CBT. Moreover, through the use of clinical examples from our practice, we suggest ways in which employment issues might be integrated into CBT for depression and anxiety disorders. We conclude that a return-to-work agenda can be utilized during therapy while maintaining a collaborative and secure therapeutic relationship, especially, perhaps if work issues are embedded within the formulation. However, further research is needed, not only to determine whether CBT can help individuals return to work but also how CBT might best integrate a return-to-work agenda.

How do we manage patients who become unemployed?

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social "vitamins" of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

Efficacy of cognitive behavioral therapy training using brief e-mail sessions in the workplace: a controlled clinical trial

In the present study, we conducted a clinical controlled trial to evaluate the effects of cognitive behavioral therapy (CBT) training in improving depression and self-esteem in workers. A total of 261 workers were assigned to either an intervention group (n=137) or a waiting-list group (n=124). The intervention group was offered participation in a group session with CBT specialists and three e-mail sessions with occupational health care staff. Between-group differences in the change in Center for Epidemiologic Studies Depression Scale (CES-D) and Self-Esteem Scale from baseline to three months after the end of training were assessed by analysis of covariance. All subjects in the intervention group completed the group session and 114 (83%) completed the three e-mail sessions. CES-D score decreased by 2.21 points in the intervention group but increased by 0.12 points in the control group, a significant difference of -2.33 points (95% confidence interval: -3.89 to-0.77; p<0.001). The between-group difference in change of self-esteem scores was not significant. Results of the present study suggest that CBT training cooperatively provided by CBT specialists and occupational health care staff using brief e-mail is effective in improving feelings of depression in workers.

Some Implications of the Psychological Experience of Unemployment

This paper presents a summary of some of the implications gleaned from a research project which investigated the psychological influences on the experience of unemployment. Drawing from deprivation theory and the stress and coping literature, the research project explored coping resources, cognitive appraisals, coping behaviours, mental health and re-employment. The results highlight the importance of considering a range of factors that could impact on the psychological wellbeing, job search behaviour and re-employment prospects for unemployed individuals. some of those factors include core self-evaluations, appraisals of deprivation or hardship, and activities that individuals pursue in their spare time. suggestions are made for intervention strategies that can be tailored to the specific need of the individual.

Effect of a vocationally-focused brief cognitive behavioural intervention on employment-related outcomes for individuals with mood and anxiety disorders

Despite an increasing emphasis on the importance of vocational success to the quality of life of individuals with mental illness (Bond, Drake, & Becker, 2008), minimal work has examined the impact of cognitive behavioural interventions that focus on vocational stressors. Vocational stressors commonly faced by persons with mental illness include difficulties with work task completion, obtaining employment, and coping with interpersonal stressors (Becker et al., 1998). The purpose of this pilot study was to examine the effectiveness of a brief cognitive behavioural therapy group intervention that targets vocational stressors for individuals whose vocational functioning had been significantly impacted by mental illness. Participants included 16 individuals with mood and anxiety disorder diagnoses. After this intervention, it was found that employed persons reported an improved sense of mastery in the completion of work tasks, improved satisfaction with work supervision, and decreased satisfaction with advancement and job security. Unemployed participants reported improved expectancy for employment success.

The effect of a job placement and support program for workers with musculoskeletal injuries: a randomized control trial (RCT) study

BACKGROUND

This is a randomized clinical trial (RCT) to investigate the efficacy of a job placement and support program designed for workers with musculoskeletal injuries and having difficulties in resuming the work role. The program was planned to help injured workers to successfully return to work (RTW) by overcoming the difficulties and problems during the process of job seeking and sustaining a job using a case management approach.

METHODOLOGY

A total of 66 injured workers were recruited and randomly assigned into the job placement and support group (PS group) or the self-placement group (SP group). A three-week job placement and support program was given to subjects in the PS group while subjects in the control group (SP group) were only given advice on job placement at a workers' health center. The PS program was comprised of an individual interview, vocational counseling, job preparation training, and assisted placement using the case management approach. The Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), the Chinese State Trait and Anxiety Inventory (C-STAI), and the SF-36 were the outcome measures for the two groups before and after the training program to observe the changes in subjects' work readiness status, emotional status and their health related quality of life pre- and post-training program. The rate of return to work was measured for both groups of subjects after the training program.

RESULTS

The results indicated that the rate of success in RTW (73%) was significantly higher in the job placement (PS) group than that of the self-placement (SP) group (51.6%) with P < 0.05. Significant differences were also found in C-STAI (P < 0.05), SF-36 (P < 0.05) and C-LASER scores on action (P < 0.05) between the two groups.

CONCLUSION

The job placement (PS) program appeared to have enhanced the employability of injured workers. Workers who participated in the program also showed higher levels of work readiness and emotional status in coping with their work injuries.

Measuring return to work

BACKGROUND

It is argued that one of the factors limiting the understanding of return to work (RTW) following work disability is the use of measurement tools that do not capture a complete picture of workers' RTW experiences. To facilitate the investigation of RTW, the current authors proposed a developmental conceptualization of RTW, which argues for an expanded awareness that encompasses four phases: off work, work reintegration, work maintenance and advancement. This paper reports on work undertaken with the aim of operationalizing the conceptualization.

METHODS

A review of the RTW and related literature, with databases searched including PubMed, EconLit, and PsycInfo. We began by extracting details of RTW instruments used by previous researchers. We then interpreted these within the context of the phases of RTW. Using the International Classification of Functioning, Disability, and Health (ICF) to inform our thinking and coding structure, we conceptualized phase-based RTW outcomes and categorized them as 'tasks and actions', 'contextual' or 'process driven'. Iteratively, we reviewed existing instruments for their use as measures of RTW. Where gaps in instrumentation were found, the wider vocational and career assessment literature was searched for instruments that could be adapted for use in RTW research.

RESULTS

Results indicate that, although numerous research instruments have been used to assess RTW, within the scientific literature some important dimensions of RTW lack instrumentation. In particular, we found that outcomes such as goal setting, motivation, expectation, job seeking, work maintenance, and career advancement require operationalization. Amongst the outcomes had been operationalized, we found considerable variation in conceptual development and application.

CONCLUSIONS

The lack of consistency and comprehensiveness of RTW measurement is one of the factors compromising the advancement of the field of RTW research. It is suggested that a more complete and psychometrically sound array of research instruments, grounded within a commonly adopted paradigm, would further the understanding of RTW and the factors affecting it.

Suicide and unemployment: what are the missing links?

The suicide rate has been paralleled by an upward trend of unemployment in Hong Kong since 1997. This study aims to explore the unknown suicide-related factors among the unemployed. This information is useful in developing culturally specific suicide prevention initiatives related to unemployment. Seventy-six suicide deceased and 15 life subjects who were unemployed were selected from a previous psychological autopsy study. Logistic regression models were employed to estimate the relative suicide risks among the unemployed people. Among the unemployed, the suicide deceased were more likely to be male, had suffered from psychiatric illness, and had attempted suicide before. They also had acquired less competent social problem solving skills. Comparison with a small control group creates a generalizability problem. Suicide prevention for the unemployed could be done through mental health awareness programs; problem-solving skills training for attempters and males; and vocational training and job opportunities for discharged psychiatric patients and rehabilitees.