Cognitive work hardening for return to work following depression: An intervention study: Le réentraînement cognitif au travail pour favoriser le retour au travail à la suite d'une dépression : étude d'intervention

Cost-effectiveness of occupational therapy return-to-work interventions for people with mental health disorders: A systematic review

BACKGROUND

Return-to-work (RTW) resources for persons with mental health disorders are limited and costs are typically shared by several stakeholders in society. Occupational therapists (OT) provide RTW interventions for this target group, however, increased knowledge of health, and employment effects, as well as costs are needed to better inform decision makers in their prioritisations.

AIMS/OBJECTIVES

To identify and summarise evidence of cost-effectiveness of RTW interventions for persons with mental health disorders which OTs provide.

MATERIALS AND METHODS

A systematic search was applied and resulted in 358 articles. After screening, nine articles met inclusion criteria and were reviewed. Quality assessment was conducted using the economic evaluation tool by Joanna Briggs Institute.

RESULTS

Supported employment, Individual Placement and Support was cost-effective in several contexts while three studies showed larger effects and higher costs. An OT intervention added to treatment for major depression was indicated to be cost-beneficial and an advanced supported employment was cost-saving. The methodological quality varied considerably between studies.

CONCLUSIONS AND SIGNIFICANCE

The results of the included studies are promising, however, to further strengthen the economic perspective in OT RTW interventions, the need for conducting more and methodologically robust economic evaluations is crucial in future studies.

Return to Work for People with Common Mental Disorders: Insights into the Implementation of a Collaborative Program in a Specialized Mental Health Hospital

Purpose Common mental disorders (CMDs) are a major cause of sick leave. Return-to-work (RTW) interventions providing mechanisms that support the participation and collaboration of the different stakeholders appear promising in these circumstances. The Therapeutic Return-to-Work (TRW) Program offers such mechanisms designed to enable affected workers to fully reintegrate into their jobs on a sustainable basis. This study evaluated the feasibility of implementing this program for workers with CMDs, within a specialized mental health hospital. Methods The study was conducted using a multiple case design and three main data sources: (1) the worker's medical file, (2) the log completed by the clinicians, and (3) individual interviews with stakeholders. Data were analyzed using a qualitative approach. Results Twelve workers between 32 and 60 years old, mostly women with complex mental health profiles working in large enterprises, participated in this study. Three main observations were made regarding the TRW Program implementation: (1) eight cases were characterized by complete or virtually complete implementation; (2) no explanatory factor could be identified for the different implementation levels; (3) eight cases achieved RTW success (RTW to the original job or another job), which appears partially attributable to the high level of program implementation. Conclusions: The TRW Program seems highly promising for supporting the return to work of workers with CMDs. However, studies identifying the factors likely to influence the implementation process in different health service contexts and specifying the scope and nature of the program's actual impact on RTW outcomes should be conducted before larger-scale implementation takes place.

Outcomes of an interdisciplinary return to work intervention including occupational therapy for mood and adjustment disorders: A single-arm clinical trial

BACKGROUND

Mood and adjustment disorders are two major causes of long-term sick leave among employees, leading to large social losses. Therefore, a return to work (RTW) intervention was attempted, targeting patients with mood and adjustment disorders.

OBJECTIVE

This study aimed to investigate the outcome of an interdisciplinary RTW intervention including occupational therapy implemented within the Japanese healthcare framework.

METHODS

An interdisciplinary RTW intervention including occupational therapy was conducted five times a week for approximately three months, targeting individuals with mood and adjustment disorders who took a leave of absence. Their mental symptoms, cognitive functioning, job performance, temperament, social adaptation, psychosocial state, and readiness to RTW before and after the intervention were evaluated. Full-time RTW ratios at 3, 6, 12, 18, and 24 months from baseline were followed up and compared with those of prior studies.

RESULTS

A total of 30 individuals completed the intervention. After the intervention, participants' psychological symptoms, cognitive function, vocational aptitude, temperament, social adaptation, psychosocial state, and readiness to RTW improved (p≤0.001-0.0279). The ratios of RTW at 3, 6, 12, 18, and 24 months from the baseline were 6.7%, 46.7%, 73.3%, 77.8%, and 82.6%, respectively, reflecting a higher pattern than prior reports.

CONCLUSIONS

The interdisciplinary RTW intervention including occupational therapy has the potential to improve not only depressive symptoms but also cognitive functioning, job performance, social adaptation, and readiness to RTW. They can also raise RTW ratios.

Sick leave duration as a potential marker of functionality and disease severity in depression

Objective: To discuss the impact of depression on work and how depression-related sick leave duration could be a potential indicator and outcome for measuring functionality in depression.Methods: Our review was based on a literature search and expert opinion that emerged during a virtual meeting of European psychiatrists that was convened to discuss this topic.Results: Current evidence demonstrates that depression-related sick leave duration is influenced by multiple disease-, patient- and work-related factors, together with societal attitudes towards depression and socioeconomic conditions. A wide variety of pharmacological and non-pharmacological treatments and work-based interventions are effective in reducing depression-related sick leave duration and/or facilitating return to work. Recent real-world evidence showed that patients treated with antidepressant monotherapy appear to recover their working life faster than those receiving combination therapy. Although depression-related sick leave duration was found to correlate with severity of depressive symptoms, it cannot be used alone as a viable marker for disease severity.Conclusions: Given its multifactorial nature, depression-related sick leave duration is not on its own a viable outcome measure of depression severity but could be used as a secondary outcome alongside more formal severity measures and may also represent a useful measure of functionality in depression. Key pointsDepression in the working population and depression-related sick leave have a profound economic impact on societyDepression-related sick leave duration is influenced by multiple disease-, patient- and work-related factors, together with societal attitudes towards depression and socioeconomic conditionsA wide variety of pharmacological and non-pharmacological treatments and work-based interventions have been shown to be effective in reducing depression-related sick leave duration and/or facilitating return to workIn terms of pharmacological intervention, recent real-world evidence has shown that patients treated with antidepressant monotherapy are able to recover their working life faster than those treated with combination therapyAlthough depression-related sick leave duration has been shown to correlate with severity of depressive symptoms, it is not a viable outcome measure of depression severity on its own, but could be used as secondary outcome alongside more formal clinician- and patient-rated severity measuresDepression-related sick leave duration may, however, represent a viable outcome for measuring functionality in depression.

Healthy Minds: Group Cognitive-Behavioral Intervention for Sustainable Return to Work After a Sick Leave Due to Depression

Background Depression is one of the major causes for sick leave and loss of productivity at work. Many studies have investigated return to work (RTW) interventions for people with common mental disorders. However, a paucity of studies has targeted depressive symptoms in the workplace, as well as work productivity. Objectives This study presents preliminary results on a novel group intervention based on cognitive behavioral principles in order to optimize sustainable RTW, by reducing clinical symptoms (anxiety and depression) and improving work productivity. Method This pilot study followed a quasi-experimental design, with participants randomly receiving the group intervention (N = 19) or only receiving usual services (N = 11, control group). The group intervention called Healthy Minds for Sustainable RTW consists of eight sessions based on cognitive behavioral therapy principles and techniques. Outcome measures on depressive and anxiety symptoms and work productivity were administered at baseline (i.e. the start of return-to-work or gradual RTW), as well 2 months later (post-intervention), and at 6-month follow-up. Results The results did not show a time × group interaction for symptoms of depression or anxiety (p = 0.07). Those who received the group intervention however did see a within-group reduction in anxiety and depressive symptoms over time, clinically significant for the group intervention only. A significant time × group interaction for work productivity was found, with those in the intervention group improving over time compared to the control condition. Conclusion Although replication is needed, these results suggest that a brief group cognitive-behavioral intervention specifically tailored to work-related issues is promising. Future studies are warranted, particularly with larger samples and remote webconferencing delivery.

Long-term effect of a care manager on work ability for patients with depression – the PRIM-CARE RCT

BACKGROUND: Collaborative care with a care manager in primary care improves care. OBJECTIVE: To study whether care manager support leads to improved work ability, decreased job strain and reduced time of sick leave among primary care patients with depression. METHODS: A clinical effectiveness study of care managers for depression patients seeking care in primary care was conducted in a RCT 2014 –2016. Patients in the intervention group were assigned a care manager. In the 12-month follow-up, patients with employment (n = 269; intervention n = 142, control n = 127) were studied concerning work ability, job strain and sick leave. RESULTS: An association was shown between reduction of depressive symptoms and improved work ability for the entire group. At 12-month follow-up a statistically significant difference of reduction of depressive symptoms was seen between the groups (MADRS-S: intervention 10.8 vs control 13.1, p = 0.05) as well as increased quality of life (EQ-5D: intervention 0.77 vs control 0.70, p = 0.04). In the intervention group, a concordance was found between the patient’s prediction of return to work and the actual return to work (91%for intervention and 68 %for control group, p = 0.047). CONCLUSIONS: Compared to usual care, the care manager does not seem to further improve perception of work ability, job strain or perception of social support per se among the patients despite a long-term effect on depression symptoms. The lack of a long-term effect regarding these aspects may be due to the fact that care manager support was only provided during the first three months.

[Enabling Workers to Preserve Their Mental Health: What are Ocupational Therapists Doing?]

Background. Occupational therapists support workers who have experienced a mental health issue in their return-to-work process, but can also support the maintenance of long-term healthy participation. Little scientific literature exists to understand this emerging role. Purpose. To describe occupational therapists' interventions with respect to enabling workers to maintain their mental health. Method. Using a descriptive qualitative design, interviews were conducted with 19 occupational therapists working in socioprofessional rehabilitation. Findings. Occupational therapists reported to implemente 31 interventions, devided in eight categories. These interventions were mainly focused on the workers themselves; those involving the environment were less developed. Implications. The interventions described with specificity offer concrete levers that occupational therapists can use in their practice. However, research is needed to evaluate the effectiveness of these interventions.

Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists

Work rehabilitation refers to the process of assisting workers to remain at work or return to work (RTW) in a safe and productive manner, while limiting the negative impact of restricted work, unemployment, and work disability. The primary purpose of this clinical practice guideline (CPG) is to systematically review available scientific evidence and provide a set of evidence-based recommendations for effective physical therapy evaluation, treatment, and management of individuals experiencing limitations in the ability to participate in work following injury or illness. J Orthop Sports Phys Ther 2021;51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

A systematic review into the effectiveness of occupational therapy for improving function and participation in activities of everyday life in adults with a diagnosis of depression

BACKGROUND

Depression is a common mental health disorder, the symptoms of which can disrupt functioning and lead to reduced participation in everyday activities.  Occupational therapy is routinely provided for people with such difficulties; however, the evidence underpinning this intervention for depression has yet to be systematically assessed.

METHOD

A systematic review of the effectiveness of occupational therapy for people with a diagnosis of depression, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was undertaken. Seven databases were searched using terms for depression combined with terms associated with occupational therapy. Due to heterogeneity in study design and outcome measures, a best evidence synthesis was undertaken as an alternative to meta-analysis.

RESULTS

Of 1962 articles identified, 63 full texts were assessed and six met the inclusion criteria. Studies were carried out in Canada, Germany, the Netherlands, Taiwan and the United Kingdom. There was strong evidence for the effectiveness of occupational therapy return-to-work interventions for improving depression symptomology, limited evidence for occupational therapy lifestyle interventions for reducing anxiety and suicidal ideation, and limited evidence for improving work participation.  No studies evaluated individualised client-centred occupational therapy, highlighting a gap in research.

LIMITATIONS

Incomplete reporting within studies and heterogeneity prevented meta-analysis.  English language restrictions were applied.

CONCLUSIONS

Whilst overall the evidence base for occupational therapy for depression is limited, strong evidence was found for the effectiveness of occupational therapy return-to-work interventions, which is important given the costs associated with mental ill-health and work absence. Further research is needed to strengthen the evidence base.

Case Report: Cognitive Work Hardening for Return-to-Work Following Depression

The growing number of mental health disability claims and related work absences are associated with a magnitude of human, economic and social costs with profound impact on the workplace. In particular, absences due to depression are prevalent and escalating. There is a need for treatment interventions that address the unique challenges of people returning to work following an episode of depression. Occupational functioning often lags depression symptom improvement which necessitates targeted treatment. Cognitive work hardening (CWH) is a multi-element, work-oriented intervention with empirical research supporting its role in return-to-work following a depressive episode. This case report details the use of CWH to prepare an individual to return to work following a disability leave due to depression. It illustrates how CWH bridges the functional gap between being home on disability and returning to competitive employment. The client presented is a 50 year old divorced woman who had been off work for approximately 2 years for depression precipitated by the terminal illness of her mother. She participated in a 4 week CWH program which addressed fatigue and decreased stamina, reduced cognitive abilities, outdated computer skills, and heightened anxiety. Work simulations enabled the rebuilding of cognitive abilities with concomitant work stamina; task mastery bolstered self-confidence and feelings of self-efficacy; and coping skill development addressed the need for stress management and assertive communication strategies. By program completion, the client's self-reported work ability had increased and both fatigue and depression symptom severity had decreased. Clinical markers of work performance indicated that the client was ready to return to her pre-disability job. Three months after completion of CWH, the client reported that she was at work, doing well and working full days with good stamina and concentration. This report provides insight into how CWH can be applied to return-to-work preparation following depression with positive outcomes.

The experiences of care managers and rehabilitation coordinators of a primary care intervention to promote return to work for patients with common mental disorders: a qualitative study

BACKGROUND

In an earlier study, PRIM-CARE RCT, a care manager implementation at the primary care centre showed improved return to work and reduced sick leave for patients with CMD. To further improve return to work, the project Co-Work-Care added a person-centered dialogue meeting between the patient, the employer and the rehabilitation coordinator, preceded by an increased collaboration between care manager, rehabilitation coordinator and GP. In this first qualitative study of the Co-Work-Care project, we explored how care managers and rehabilitation coordinators experienced the Co-Work-Care model. The purpose of this study was to explore care managers' and rehabilitation coordinators' perceptions and experiences of a close collaboration and the use of the person-centred dialogue meeting.

METHODS

From an ongoing RCT with 20 primary care centres, care managers (CMs) (n = 13) and rehabilitation coordinators (RCs) (n = 12) participated in a qualitative study with focus groups. The study was conducted in the primary health care in a Swedish region. The data was analysed with Systematic Text Condensation by Malterud.

RESULTS

Seven codes describing the participants' experiences of the Co-Work-Care model were identified: 1) The importance of collaboration at the primary care centre, 2) Collaboration and division of roles between the RC and the CM, 3) Collaboration with the General practitioner (GP), 4) The person-centred dialogue meeting, 5) Initiating the person-centred dialogue meeting, 6) The person-centred dialogue meeting to improve collaboration with the employer, and 7) The person-centred dialogue meeting to teach about the return to work process.

CONCLUSION

The increased collaboration within the Co-Work-Care model created a common picture and understanding of the patient's situation. The person-centred dialogue meeting in the rehabilitation process became a bridge between the employer and the patient.

TRIAL REGISTRATION

NCT03250026 (registered August 15, 2017).

Interventions to improve return to work in depressed people

BACKGROUND

Work disability such as sickness absence is common in people with depression.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library), MEDLINE, Embase, CINAHL, and PsycINFO until April 4th 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar.  MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up.  Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up.   Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms.

AUTHORS' CONCLUSIONS

A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best.

Occupational therapy interventions in mental health: a scoping review of recent evidence

Background/Aims

Studies investigating the effect of occupational therapy in mental health are few. This scoping review aims to identify, present and assess studies that have investigated the effect of occupation- and activity-based/focused interventions performed by occupational therapists in mental health.

Methods

The scoping review involved searching six databases, covering articles from 2003 to 2018. ‘The Matrix Method’ was used to describe and synthesise the content of the included studies. The Oxford Level of Evidence was used to rank the evidence, and The Critical Appraisal Skills Programme was used to assess the quality of the study.

Results

A total of 21 original studies and 4 systematic reviews were included in this review. Interventions, approaches, programmes, training, and activities such as cooking, artwork, crafts, pottery, sports, calligraphy, horticulture, and music, organised individually or in groups, were investigated in the included studies. Individualised occupational therapy showed clinically significant improvements in social functioning and cognition, promising results were found on supported employment and education.

Conclusions

Few high-quality studies that have investigated the effect of occupation-and activity-based/focused interventions performed by occupational therapists in mental health were found. This scoping review highlights the importance of future high quality studies to support evidence-based practice within mental health occupational therapy.

Workplace mental health: Current practice and support needs of Ontario occupational therapists

Background.

Workplace mental health (WMH) is an important and expanding practice area for occupational therapists.

Purpose.

This cross-sectional study explores the current practices and support needs of Ontario-based occupational therapists in WMH.

Method.

Registrants from the provincial association who provide mental health and/or work-related services were invited to participate. Ninety-three therapists completed an online survey; 10 participated in follow-up focus groups. Analysis involved descriptive statistics of the survey data and content analysis of the focus group data.

Findings.

Return to work, reactivation, and functional cognitive assessment were the most commonly reported services. Key challenges were limited funding and training and lack of awareness of the occupational therapy role. Therapists emphasized the importance of raising the competence, credibility, and profile of occupational therapy in WMH.

Implications.

Defining the role of occupational therapy, developing training and resources, and advocacy are needed to advance occupational therapy practice within this rapidly changing field.