Occupational Functioning Scale (OFS)--an instrument for assessment of work ability in psychiatric disorders

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Socio-economic consequences of mental distress: quantifying the impact of self-reported mental distress on the days of incapacity to work and medical costs in a two-year period: a longitudinal study in Germany

BACKGROUND

Mental disorders are related to high individual suffering and significant socio-economic burdens. However, it remains unclear to what extent self-reported mental distress is related to individuals' days of incapacity to work and their medical costs. This study aims to investigate the impact of self-reported mental distress for specific and non-specific days of incapacity to work and specific and non-specific medical costs over a two-year span.

METHOD

Within a longitudinal research design, 2287 study participants' mental distress was assessed using the Hospital Anxiety and Depression Scale (HADS). HADS scores were included as predictors in generalized linear models with a Tweedie distribution with log link function to predict participants' days of incapacity to work and medical costs retrieved from their health insurance routine data during the following two-year period.

RESULTS

Current mental distress was found to be significantly related to the number of specific days absent from work and medical costs. Compared to participants classified as no cases by the HADS (2.6 days), severe case participants showed 27.3-times as many specific days of incapacity to work in the first year (72 days) and 10.3-times as many days in the second year (44 days), and resulted in 11.4-times more medical costs in the first year (2272 EUR) and 6.2-times more in the second year (1319 EUR). The relationship of mental distress to non-specific days of incapacity to work and non-specific medical costs was also significant, but mainly driven from specific absent days and specific medical costs. Our results also indicate that the prevalence of presenteeism is considerably high: 42% of individuals continued to go to work despite severe mental distress.

CONCLUSIONS

Our results show that self-reported mental distress, assessed by the HADS, is highly related to the days of incapacity to work and medical costs in the two-year period. Reducing mental distress by improving preventive structures for at-risk populations and increasing access to evidence-based treatments for individuals with mental disorders might, therefore, pay for itself and could help to reduce public costs.

Assessment of Capacity Impairment in Patients with Mental Disorders by Routine Clinical Assessment and by Structured Assessment with the Mini-ICF-APP

BACKGROUND

Physicians and therapists are also consulted to give judgments on working ability. Ability to work cannot simply be derived from the patient's symptom status but from the illness-related capacity impairments in relation to the work demands. A structured assessment of capacity impairments has been evaluated and applied internationally: the Mini-ICF-APP Social Functioning Scale. It is currently unclear whether a free-text clinical report (i.e., usual clinical practice: clinical exploration according to clinical standards, but without a standardized documentation form, instead a text is written) and a structured capacity assessment correspond to the overall work ability judgment, i.e., the decision whether a patient is "fit for work" or "unfit for work."

OBJECTIVES

This investigation assessed, for the first time, whether usual clinical judgment and the additional structured capacity rating support the work ability decision.

METHODS

A total of 100 medical reports from patients in a psychotherapy hospital were excerpted for psychopathological symptoms and capacity disorders using a checklist. Additionally, a structured assessment of capacity disorders was documented on the Mini-ICF-APP rating for all patients.

RESULTS

In the free-text clinical medical report, endurance, flexibility, and contacts to others were the things mainly reported as impaired. This was similar to the structured Mini-ICF-APP rating. However, other capacity impairments were also reported in the Mini-ICF-APP, i.e., adherence to rules and regulations, planning and structuring, assertiveness, and group integration. When the free-text clinical report and the structured Mini-ICF-APP rating were compared, there was a higher rate of stated impairments covering all capacity dimensions in the Mini-ICF-APP rating.

CONCLUSIONS

The free-text report in the medical report shows the differences between patients who are fit for work and those who are not, and thus speak for the validity of work ability decisions. However, optimization is possible in terms of depth and differentiation of capacity impairment description by adhering to the standard set by the Mini-ICF-APP.

Occupational Functionality: A Concept Analysis

Occupational health nursing has evolved since the late 19th century and, with the inclusion of advanced practice nursing, has become essential to the health and safety of workers. A key component of the knowledge required of advanced practice occupational health nurses is an understanding of what it means for workers to be fit for duty The definition or concept of being fit for duty varies depending on the point-of-view of the health care provider. Health care providers across all professions must have a consistent understanding of what it means to be fit for duty Literature shows that professions and specialties that often collaborate have varying ideas about what it means to be fit for duty These differences highlight the need for a consistent concept that can be used across professions, is holistic, and incorporates other concepts critical to all points of view. To better understand fit for duty, a concept analysis, using the Walker and Avant framework, focused on the concept of occupational functionality (OF). Occupational functionality is best defined as the qualities of being suited to serve an occupational purpose efficiently and effectively within the physical, occupational, environmental, and psychological demands of a unique work setting. This concept analysis offers an initial step in understanding fit for duty and gives health care providers a concept that can be used across disciplines.

Inter-rater agreement in evaluation of disability: systematic review of reproducibility studies

OBJECTIVES

 To explore agreement among healthcare professionals assessing eligibility for work disability benefits.

DESIGN

 Systematic review and narrative synthesis of reproducibility studies.

DATA SOURCES

 Medline, Embase, and PsycINFO searched up to 16 March 2016, without language restrictions, and review of bibliographies of included studies.

ELIGIBILITY CRITERIA

 Observational studies investigating reproducibility among healthcare professionals performing disability evaluations using a global rating of working capacity and reporting inter-rater reliability by a statistical measure or descriptively. Studies could be conducted in insurance settings, where decisions on ability to work include normative judgments based on legal considerations, or in research settings, where decisions on ability to work disregard normative considerations. : Teams of paired reviewers identified eligible studies, appraised their methodological quality and generalisability, and abstracted results with pretested forms. As heterogeneity of research designs and findings impeded a quantitative analysis, a descriptive synthesis stratified by setting (insurance or research) was performed.

RESULTS

 From 4562 references, 101 full text articles were reviewed. Of these, 16 studies conducted in an insurance setting and seven in a research setting, performed in 12 countries, met the inclusion criteria. Studies in the insurance setting were conducted with medical experts assessing claimants who were actual disability claimants or played by actors, hypothetical cases, or short written scenarios. Conditions were mental (n=6, 38%), musculoskeletal (n=4, 25%), or mixed (n=6, 38%). Applicability of findings from studies conducted in an insurance setting to real life evaluations ranged from generalisable (n=7, 44%) and probably generalisable (n=3, 19%) to probably not generalisable (n=6, 37%). Median inter-rater reliability among experts was 0.45 (range intraclass correlation coefficient 0.86 to κ-0.10). Inter-rater reliability was poor in six studies (37%) and excellent in only two (13%). This contrasts with studies conducted in the research setting, where the median inter-rater reliability was 0.76 (range 0.91-0.53), and 71% (5/7) studies achieved excellent inter-rater reliability. Reliability between assessing professionals was higher when the evaluation was guided by a standardised instrument (23 studies, P=0.006). No such association was detected for subjective or chronic health conditions or the studies' generalisability to real world evaluation of disability (P=0.46, 0.45, and 0.65, respectively).

CONCLUSIONS

 Despite their common use and far reaching consequences for workers claiming disabling injury or illness, research on the reliability of medical evaluations of disability for work is limited and indicates high variation in judgments among assessing professionals. Standardising the evaluation process could improve reliability. Development and testing of instruments and structured approaches to improve reliability in evaluation of disability are urgently needed.

Use of a structured functional evaluation process for independent medical evaluations of claimants presenting with disabling mental illness: rationale and design for a multi-center reliability study

BACKGROUND

Work capacity evaluations by independent medical experts are widely used to inform insurers whether injured or ill workers are capable of engaging in competitive employment. In many countries, evaluation processes lack a clearly structured approach, standardized instruments, and an explicit focus on claimants' functional abilities. Evaluation of subjective complaints, such as mental illness, present additional challenges in the determination of work capacity. We have therefore developed a process for functional evaluation of claimants with mental disorders which complements usual psychiatric evaluation. Here we report the design of a study to measure the reliability of our approach in determining work capacity among patients with mental illness applying for disability benefits.

METHODS/DESIGN

We will conduct a multi-center reliability study, in which 20 psychiatrists trained in our functional evaluation process will assess 30 claimants presenting with mental illness for eligibility to receive disability benefits [Reliability of Functional Evaluation in Psychiatry, RELY-study]. The functional evaluation process entails a five-step structured interview and a reporting instrument (Instrument of Functional Assessment in Psychiatry [IFAP]) to document the severity of work-related functional limitations. We will videotape all evaluations which will be viewed by three psychiatrists who will independently rate claimants' functional limitations. Our primary outcome measure is the evaluation of claimant's work capacity as a percentage (0 to 100 %), and our secondary outcomes are the 12 mental functions and 13 functional capacities assessed by the IFAP-instrument. Inter-rater reliability of four psychiatric experts will be explored using multilevel models to estimate the intraclass correlation coefficient (ICC). Additional analyses include subgroups according to mental disorder, the typicality of claimants, and claimant perceived fairness of the assessment process.

DISCUSSION

We hypothesize that a structured functional approach will show moderate reliability (ICC ≥ 0.6) of psychiatric evaluation of work capacity. Enrollment of actual claimants with mental disorders referred for evaluation by disability/accident insurers will increase the external validity of our findings. Finding moderate levels of reliability, we will continue with a randomized trial to test the reliability of a structured functional approach versus evaluation-as-usual.

[Working disability evaluation of mentally ill persons in times of socioeconomic crisis]

INTRODUCTION

Mental disorders reduce social functioning of ill persons in general and often cause permanent work disability. Psychiatric services try to solve individual professional or financial status in economic crisis conditions. The possible causes of disability in psychiatric patients, besides illness, are psychosocial factors. The aim of this research was to determine the number of mentally ill persons as well as morbidity structure changes in work disability evaluation in the last five years.

MATERIAL AND METHODS

The research included 617 psychiatric patients referred for work disability evaluation in this five-year period (2004-2008). The data contained gender, age, psychiatric diagnosis and the suggested level of disability.

RESULTS AND CONCLUSION

In the morbidity structure, a significant increase was found in the group of patients with psychoactive substance abuse, in whom the likelihood of permanent work disability was frequent. A significant decrease was observed in the group of patients with mental retardation. The number of patients with schizophrenia was similar in the study period. The patients with mood disorders, neurotic, stress-related and somatoform disorders were present in a relatively high number. The evaluation and suggestion for permanent work disability increased statistically significantly, while the number of patients in need for material security decreased in the period of socioeconomic crisis. Disability trend in the population of mentally ill patients is still not favourable, and therefore, their work disability monitoring is an adequate parameter which identifies work inefficacy and unemployment as an important factor of a poor life quality in psychiatric patients.

Exposure-in-vivo containing interventions to improve work functioning of workers with anxiety disorder: a systematic review

BACKGROUND

Anxiety disorders are associated with functional disability, sickness absence, and decreased productivity. Effective treatments of anxiety disorders can result in remission of symptoms. However the effects on work related outcomes are largely unknown. Exposure in vivo is potentially well fit to improve work-related outcomes. This study systematically reviews the effectiveness of exposure-in-vivo containing interventions in reducing work-related adverse outcomes in workers with anxiety disorders.

METHODS

A systematic study search was conducted in Medline, Cinahl, Embase and Psycinfo. Two reviewers independently extracted data and from each study assessed the quality of evidence by using the GRADE approach. We performed a meta-analysis if data showed sufficient clinical homogeneity.

RESULTS

Seven studies containing 11 exposure-in-vivo interventions were included. Four studies were focused on Obsessive Compulsive Disorder (OCD), two on Post Traumatic Stress Disorder (PTSD), and one on a mixed group of OCD and severe phobias. The studies were grouped according to type of anxiety disorder and subsequently according to type of comparisons. For OCD, exposure-in-vivo containing interventions can yield better work-related outcomes compared to medication (SSRIs) and relaxation but not better compared to response prevention. The results on anxiety outcomes were similar. The net contribution of exposure in vivo in two OCD intervention programs is also presented as a meta-analysis and shows significant positive results on work role limitations. The calculated pooled effect size with 95% confidence interval was 0.72 (0.28, 1.15). For PTSD, exposure-in-vivo containing interventions can yield better work-related and anxiety-related outcomes compared to a waiting-list but not better compared to imaginal exposure.

CONCLUSIONS

Exposure in vivo as part of an anxiety treatment can reduce work-related adverse outcomes in workers with OCD and PTSD better than various other anxiety treatments or a waiting-list. We recommend that it should be studied how the results of these studies can be transferred to the practice of occupational health professionals and how clinicians can make better use of them to improve work-related outcomes. In future research, priority should be given to high-quality randomised controlled trials (RCTs) in which exposure-in-vivo containing interventions are applied to a variety of anxiety disorders and compared with other clinical anxiety treatments such as SSRIs. Work-related outcomes, in particular work functioning and sickness absence, need to be assessed with reliable and valid measures.

The importance of functional impairment to mental health outcomes: a case for reassessing our goals in depression treatment research

Outcomes in depression treatment research include both changes in symptom severity and functional impairment. Symptom measures tend to be the standard outcome but we argue that there are benefits to considering functional outcomes. An exhaustive literature review shows that the relationship between symptoms and functioning remains unexpectedly weak and often bidirectional. Changes in functioning often lag symptom changes. As a result, functional outcomes might offer depression researchers more critical feedback and better guidance when studying depression treatment outcomes. The paper presents a case for the necessity of both functional and symptom outcomes in depression treatment research by addressing three aims-1) review the research relating symptoms and functioning, 2) provide a rationale for measuring both outcomes, and 3) discuss potential artifacts in measuring functional outcomes. The three aims are supported by an empirical review of the treatment outcome and epidemiological literatures.

Influence of mental disorders on working ability assessment

Background/Aim. There is an increasing need for evaluation of working ability due to lower level of social protection of workers and growing number of patients with mental diseases in Bosnia and Herzegovina (B&H). The aim of this study was to establish the influence of mental diseases on the occurrence of disability of I and III categories in B&H during the period from January 1st 2005 to December 31st 2006. Methods. This study involved 1 792 examinees with the complete loss of working ability (I disability category) (n = 921). Disability category III consisted of persons with limited working ability (n = 871). The instruments of research in this multricentric and retrospective study were the forms P-6 and D-2 for the years of service in B&H, and the form IN for persons with years of service abroad and personal features questionnaire (EPQ). Results. The study included 1 494 men (78.5%) and 298 women (21.5%). Univariant analysis represented very high statistical significance (p = 0.001) concerning: age (?2 = 65.428), years of service (?2=28.438), drinking (?2 = 33.234), smoking (?2=70.880), father?s education (?2 = 58.124), migrations (?2 = 14.874), sick leave (?2 = 29.190), medical treatment (?2 = 95.073) and rehabilitation (?2 = 29.453). Multivariant analysis represented the influence on disability category I by parameters such as: years of service, sick leave, psychoticism and depression (p = 0.001). Hospital treatment and fatigation had influence on disability in both groups. Mental diseases are the leading cause in disability category I in 14.98% and in disability category III in 9.3% persons. Leading diseases in both disability categories were depression and schizophrenia followed by alcoholism, anxiety, brain organ psychosyndrome (BOPS) and other diseases. Conclusion. The following parameters have highest influence on the disability category: the years of service, sick leave, psychoticism, depression, and long-lasting disease, medical treatments and fatigation on the disability category III.