Depression as a predictor of work resumption following myocardial infarction (MI): a review of recent research evidence

[Work Participation after Multimodal Rehabilitation due to Cardiovascular Diseases - Representative Analyses using Routine Data of the German Pension Insurance]

PURPOSE

Cardiovascular diseases represent a large proportion of the disease burden of the adult population in Germany. Their importance in rehabilitation has increased continuously in recent years. Several studies have investigated return to work of cardiac patients after rehabilitation, which is relevant from the perspective of pension insurance. However, there is a lack of representative findings for the German region on employment trajectories and their influencing factors.

METHODS

The rehabilitation statistics database of the German Pension Insurance (GPI) was used for this study. Subjects were patients with cardiovascular diseases undergoing rehabilitation in 2017. Analyses were performed for the total group and differentiated by relevant diagnosis groups. Occupational participation was operationalized via a monthly state variable up to 24 months after rehabilitation and the rate of all persons who were employed at the 12- and 24- month follow-up and in the 3 months before, respectively. Multiple logistic regression models were calculated to analyze the influencing factors.

RESULTS

The total sample comprised 59,667 patients. The average age in all groups was between 53 and 56 years. Men were disproportionately represented; 70% of the services were provided as follow-up rehabilitations and 88% in the inpatient setting. Stable employment rates were 66% after one year and 63% after two years in the overall group (disease groups: 49% to 71%). The strongest influencing factors were the amount of pay and the number of sickness absence days before rehabilitation, active employment before rehabilitation, and age.

CONCLUSION

For the first time, representative data on occupational participation following rehabilitation on behalf of the GPI are available for the disease groups considered. The analyses underline the need to focus on occupational perspectives already in medical rehabilitation or directly thereafter.

Adaptation and validation of the cardiovascular version of the Return-to-Work Obstacles and Self-Efficacy Scale (ROSES-CVD) to the Italian context

PURPOSE

Effective cardiac rehabilitation interventions must provide adequate support to overcome psychosocial return-to-work (RTW) barriers. No validated instrument is available for this aim for cardiovascular patients. The Return-to-work Obstacles and Self-Efficacy Scale (ROSES) measures RTW obstacles workers perceive and the self-efficacy for overcoming them through 46 items and ten dimensions. This study aimed to adapt and validate ROSES for cardiovascular disease (CVD) in the Italian context.

METHODS

This prospective study involved 183 CVD working patients at baseline and 121 six months later. ROSES-CVD internal consistency, construct, and predictive validity was evaluated with Cronbach's α, Confirmatory factor analyses (CFA), and ANCOVAs.

RESULTS

CFAs adequately replicated the original ROSES model (CFI = .92-.96; TLI = .91-.94; RMSEA = .042-.057; SRMR = .046-.071) with α close or higher than .70 for all dimensions. Four ROSES-CVD dimensions significantly predicted the number of days to RTW controlling for age, gender, educational level, and surgery type. Workers who perceived salient RTW obstacles and low self-efficacy in any of these dimensions in mean returned to work from 38 to 53 days later.

CONCLUSIONS

The study supported the validity and reliability of ROSES-CVD. This tool can be used in rehabilitation to detect CVD patients at risk of a longer RTW process and define appropriate cardiac rehabilitation intervention.IMPLICATIONS FOR REHABILITATIONVocational rehabilitation interventions should provide tailor-made support to overcome RTW barriers based on individual risk assessmentThe Italian translation of ROSES-CVD is a valid and reliable tool to measure psychosocial barriers to RTW among CVD working patientsThe use of ROSES-CVD would allow detection of CVD patients at risk of longer RTW processAdministering ROSES-CVD can help focus traditional vocational intervention on individually relevant obstacles to RTW.

Depression symptoms reducing return to work: a meta-analysis of prospective studies

Objectives. This study was conducted to estimate the risk of return to work for people who experience symptoms of depression based on the pool of prospective data. Methods. All online articles in PubMed and Scopus which were accessible before November 2019 were searched. The odds ratios of each of the studies were pooled together to obtain an overall odds ratio. The pool of studies was with random effects. The analysis was performed based on the depression symptoms scale, type of disease and duration of follow-up. Two other aspects were examined in the analysis, one being the bias in the publication of studies and the other being the level of heterogeneity that was examined. Results. Thirty-five studies were selected for the meta-analysis. The pooled odds ratio indicates that the odds of return to work in people with depressive symptoms is 31% lower than in those without depressive symptoms. The funnel plot shows that there is asymmetry. The Egger test result was significant (p < 0.001) and there is publication bias. Conclusion. Depression symptoms after sick leave due to physical illness is a risk factor for not returning to work.

Qualitative study of barriers and facilitators encountered by individuals with physical diseases in returning and continuing to work

BACKGROUND

The number of employees with physical diseases is increasing, and there is a need for support to help them return and continue to work. To provide effective support, it is important to identify barriers and facilitators for individuals in returning and continuing to work. Previous studies have reported barriers and facilitators for specific diseases. However, few reports have dealt with these issues across various diseases. To identify a range of barriers and facilitators that may apply to different physical diseases, we conducted a qualitative analysis by interviewing patients with diverse characteristics being treated for diseases.

METHODS

We conducted semi-structured interviews based on the criteria for qualitative research. We investigated three disease groups to obtain details of barriers and facilitators: impairments that were visible to other people (mainly stroke); impairments invisible to others (mainly heart disease); and impairments that changed over time (mainly cancer). Interview transcripts were analyzed and the results reported using systematic text condensation.

RESULTS

We extracted 769 meaning units from 28 patient interviews. We categorized barriers and facilitators that were generalizable to various diseases into three themes (personal factors, workplace factors, and inter-sectoral collaboration and social resources) and 10 sub-themes (work ability, psychological impacts, health literacy, social status, family background, workplace structure, workplace system, workplace support, inter-sectoral collaboration, and social resources).

CONCLUSIONS

This study identified 10 sub-themes that can be applied for workers with physical diseases; those sub-themes may be used as a basis for communicating with those individuals about returning and continuing to work. Our results suggest that various barriers and facilitators for workers with physical diseases should be understood and addressed at medical institutions, workplaces, and support sites.

Perceived return-to-work pressure following cardiovascular disease is associated with age, sex, and diagnosis: a nationwide combined survey- and register-based cohort study

Background

Return to work is a key rehabilitation goal for people with cardiovascular disease (CVD) because employment matters to individuals and societies. However, people recovering from CVD often struggle with returning to work and maintaining employment. To identify people in need of vocational counselling, we examined the probability of feeling under pressure to return to work following CVD.

Methods

We conducted a combined survey- and register-based study in a randomly selected, population-based cohort of 10,000 people diagnosed with atrial fibrillation, heart failure, heart valve disease, or ischaemic heart disease in 2018. The questionnaire covered return-to-work items, and we reported the probabilities of feeling under pressure to return to work with 95% confidence intervals (CIs) in categories defined by sex, age, and CVD diagnosis.

Results

The survey response rate was 51.1%. In this study, we included 842 respondents (79.7% men) aged 32–85 years, who had returned to work following a sick leave. Overall, 249 (29.7%) had felt pressure to return to work. The probability of feeling under pressure to return to work ranged from 18.3% (95% CI: 13.1–24.6) among men aged > 55 years with atrial fibrillation to 51.7% (95% CI: 32.5–70.6) among women aged ≤ 55 years with atrial fibrillation. In addition, 66.0% of all respondents had not been offered vocational rehabilitation, and 48.6% of those who reported a need for vocational counselling had unmet needs. Survey responses also indicated that many respondents had returned to work before feeling mentally and physically ready.

Conclusion

A substantial proportion of people with cardiovascular disease feel under pressure to return to work, and this pressure is associated with age, sex, and diagnosis. The results show that vocational rehabilitation must be improved and emphasize the importance of ensuring that cardiac rehabilitation programmes include all core rehabilitation components.

The role of cardiac rehabilitation in vocational reintegration Belgian working group of cardiovascular prevention and rehabilitation position paper

Cardiovascular disease is one of the main causes of morbidity and sick leave in Belgium, imposing a great socio-economic burden on the contemporary healthcare system and society. Cardiac rehabilitation is an evidence-based treatment strategy that not only improves the cardiac patients' health state but also holds promise so as to facilitate vocational reintegration in the society. This position paper was developed and endorsed by the Belgian Working Group of Cardiovascular Prevention and Rehabilitation. It provides an overview of the currently available Belgian data with regard to the role of cardiac rehabilitation in return to work after an initial cardiac event. It identifies the relevant barriers and facilitators of vocational integration of cardiac patients and summarises the contemporary Belgian legal and medical framework in this regard. Cardiac rehabilitation remains a primordial component of the post-acute event management of the cardiac patient, facilitating vocational reintegrating and thereby decreasing the pressure on social security. Despite the availability of a relevant legislative framework, there is a need for well-defined algorithms to assess readiness for return to work that can be used in daily clinical practice.

Patients' expectations of returning to work, co-morbid disorders and work capacity at discharge from cardiac rehabilitation

Objective

We aimed to characterize patients after an acute cardiac event regarding their negative expectations around returning to work and the impact on work capacity upon discharge from cardiac rehabilitation (CR).

Methods

We analyzed routine data of 884 patients (52±7 years, 76% men) who attended 3 weeks of inpatient CR after an acute coronary syndrome (ACS) or cardiac surgery between October 2013 and March 2015. The primary outcome was their status determining their capacity to work (fit vs unfit) at discharge from CR. Further, sociodemographic data (eg, age, sex, and education level), diagnoses, functional data (eg, exercise stress test and 6-min walking test [6MWT]), the Hospital Anxiety and Depression Scale (HADS) and self-assessment of the occupational prognosis (negative expectations and/or unemployment, Würzburger screening) at admission to CR were considered.

Results

A negative occupational prognosis was detected in 384 patients (43%). Out of these, 368 (96%) expected not to return to work after CR and/or were unemployed before CR at 29% (n=113). Affected patients showed a reduced exercise capacity (bicycle stress test: 100 W vs 118 W, P<0.01; 6MWT: 380 m vs 421 m, P<0.01) and were more likely to receive a depression diagnosis (12% vs 3%, P<0.01), as well as higher levels on the HADS. At discharge from CR, 21% of this group (n=81) were fit for work (vs 35% of patients with a normal occupational prognosis (n=175, P<0.01)). Sick leave before the cardiac event (OR 0.4, 95% CI 0.2–0.6, P<0.01), negative occupational expectations (OR 0.4, 95% CI 0.3–0.7, P<0.01) and depression (OR 0.3, 95% CI 0.1–0.8, P=0.01) reduced the likelihood of achieving work capacity upon discharge. In contrast, higher exercise capacity was positively associated.

Conclusion

Patients with a negative occupational prognosis often revealed a reduced physical performance and suffered from a high psychosocial burden. In addition, patients’ occupational expectations were a predictor of work capacity at discharge from CR. Affected patients should be identified at admission to allow for targeted psychosocial care.

Determinants of Return to Work After Multicomponent Cardiac Rehabilitation

OBJECTIVES

To explore predictors of return to work in patients after acute coronary syndrome and coronary artery bypass grafting, taking into account cognitive performance, depression, physical capacity, and self-assessment of the occupational prognosis.

DESIGN

Observational, prospective, bicentric.

SETTING

Postacute 3-week inpatient cardiac rehabilitation (CR).

PARTICIPANTS

Patients (N=401) <65 years of age (mean 54.5±6.3y), 80% men.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Status of return to work (RTW) 6 months after discharge from CR.

RESULTS

The regression model for RTW showed negative associations for depression (odds ratio 0.52 per SD, 95% confidence interval 0.36-0.76, P=.001), age (odds ratio 0.72, 95% confidence interval 0.52-1.00, P=.047), and in particular for a negative subjective occupational prognosis (expected incapacity for work odds ratio 0.19, 95% confidence interval 0.06-0.59, P=.004; unemployment odds ratio 0.08, 95% confidence interval 0.01-0.72, P=.024; retirement odds ratio 0.07, 95% confidence interval 0.01-0.067, P=.021). Positive predictors were employment before the cardiac event (odds ratio 9.66, 95% confidence interval 3.10-30.12, P<.001), capacity to work (fit vs unfit) at discharge from CR (odds ratio 3.15, 95% confidence interval 1.35-7.35, P=.008), and maximum exercise capacity (odds ratio 1.49, 95% confidence interval 1.06-2.11, P=.022). Cognitive performance had no effect.

CONCLUSIONS

The patient's perception and expectation regarding the occupational prognosis play a crucial role in predicting return to work 6 months after an acute cardiac event and CR. These findings highlight the importance of the multimodal approach, in particular psychosocial components, of CR.

Interventions to support return to work for people with coronary heart disease

BACKGROUND

People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work.

OBJECTIVES

To assess the effects of person- and work-directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return-to-work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and independently assessed the risk of bias. We conducted meta-analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health-related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work.

MAIN RESULTS

We found 39 RCTs (including one cluster- and four three-armed RCTs). We included the return-to-work results of 34 studies in the meta-analyses.Person-directed, psychological counselling versus usual careWe included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta-analysis. Most interventions used some form of counselling to address participants' disease-related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low-certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low-certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low-certainty evidence).Person-directed, work-directed counselling versus usual careFour studies examined work-directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co-workers' fears and misconceptions regarding CHD. Work-directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD -7.52 days, 95% CI -20.07 to 5.03 days; four studies; low-certainty evidence). Work-directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate-certainty evidence).Person-directed, physical conditioning interventions versus usual careNine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low-certainty evidence). Physical conditioning interventions may result in little to no difference in return-to-work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low-certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low-certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD -7.86 days, 95% CI -29.46 to 13.74 days; four studies; low-certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate-certainty evidence).Person-directed, combined interventions versus usual careWe included 13 studies considering return to work following combined interventions in the meta-analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low-certainty evidence), and may have little to no difference on return-to-work rates at six to 12 months' follow-up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low-certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low-certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low-certainty evidence). Combined interventions probably shortened the time needed until return to work (MD -40.77, 95% CI -67.19 to -14.35; two studies; moderate-certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate-certainty evidence).Work-directed, interventionsWe found no studies exclusively examining strictly work-directed interventions at the workplace.

AUTHORS' CONCLUSIONS

Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person-directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work-directed interventions, health-related quality of life within the return-to-work process, and adverse effects.

Retorno ao trabalho de pacientes com Síndrome Coronariana Aguda

Resumo Introdução: as doenças cardiovasculares representam grande impacto de morbimortalidade para a sociedade brasileira. Objetivo: verificar o tempo para retorno ao trabalho de pacientes com Síndrome Coronária Aguda (SCA); identificar e correlacionar variáveis sociodemográficas, clínicas, psicossociais e ocupacionais que podem influenciar nesse período e no desempenho no trabalho. Métodos: estudo transversal correlacional desenvolvido em 2015-2016 com 65 pacientes com SCA que retornaram ao trabalho. Instrumentos utilizados: Questionário de Caracterização; Questionário de Avaliação do Desempenho no Trabalho; Veterans Specific Activity Questionnaire; MacNew Heart Disease Health-related Quality of Life; Escala Hospitalar de Ansiedade e Depressão; e Impacto da Doença no Cotidiano do Valvopata. Foram aplicados: o teste de Mann-Whitney; pós-teste de Dunn; e coeficiente de correlação de Spearman. Resultados: o tempo médio para retorno ao trabalho foi de 7,3 meses. Os participantes que exerciam trabalho manual apresentaram tempo maior para retorno ao trabalho. O desempenho no trabalho foi fortemente correlacionado com a qualidade de vida e inversamente com ansiedade e depressão. Conclusão: os dados apontam a necessidade de desenvolvimento de estratégias a fim de promover o retorno ao trabalho de pacientes com SCA.

Predicting return to work after acute myocardial infarction: Socio-occupational factors overcome clinical conditions

Objectives

Return to work after acute myocardial infarction (AMI), a leading cause of death globally, is a multidimensional process influenced by clinical, psychological, social and occupational factors, the single impact of which, however, is still not well defined. The objective of this study was to investigate these 4 factors on return to work (RTW) within 365 days after AMI in a homogeneous cohort of patients who had undergone an urgent coronary angioplasty.

Participants

We studied 102 patients, in employment at the time of AMI (88.24% of men), admitted to the Department of Cardiology of the University-Hospital of Ferrara between March 2015 to December 2016. Demographical and clinical characteristics were obtained from the cardiological records. After completing an interview on social and occupational variables and the Hospital Anxiety and Depression (HADS) questionnaire, patients underwent exercise capacity measurement and spirometry.

Results

Of the 102 patients, only 12 (12.76%) held a university degree, 68.63% were employees and 31.37% self-employed. The median number of sick-leave days was 44 (IQR 33–88). At day 30, 78.5% of all subjects had not returned to work, at day 60, 40.8% and at day 365 only 7.3% had not resumed working. At univariate analyses, educational degree (p = 0.026), self-employment status (p = 0.0005), white collar professional category (p = 0.020) and HADS depression score were significant for earlier return to work. The multivariate analysis confirms that having a university degree, being self-employed and presenting a lower value of HADS depression score increase the probability of a quicker return to work.

Conclusions

These findings suggest that the strongest predictors of returning to work within 1 year after discharge for an acute myocardial infarction are related more to socio-occupational than to clinical parameters.

Factors Associated With Return to Work After Acute Myocardial Infarction in China

IMPORTANCE

Return to work is an important indicator of recovery after acute myocardial infarction. Little is known, however, about the rate of returning to work within the year after an acute myocardial infarction in China, as well as the factors associated with returning to work after an acute myocardial infarction.

OBJECTIVES

To determine the rate of return to work within 12 months after acute myocardial infarction, classify the reasons why patients did not return to work, and identify patient factors associated with returning to work.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study, conducted in 53 hospitals across 21 provinces in China, identified 1566 patients who were employed at the time of the index acute myocardial infarction hospitalization and participating in the China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study of Acute Myocardial Infarction. Data collected included patients' baseline characteristics; employment status at 12 months after acute myocardial infarction; and, for those who were not employed at 12 months, potential reasons for not returning to work. A logistic regression model was fitted to identify factors associated with returning to work at 12 months. Data were collected from January 1, 2013, through July 17, 2014, and statistical analysis was conducted from August 9, 2016, to August 15, 2018.

MAIN OUTCOMES AND MEASURES

Return to work, defined as rejoining the workforce within 12 months after discharge from hospitalization for the index acute myocardial infarction.

RESULTS

Of 1566 patients (130 women and 1436 men; mean [SD] age, 52.2 [9.7] years), 875 patients (55.9%; 95% CI, 53.4%-58.3%) returned to work by 12 months after acute myocardial infarction. Among the 691 patients who did not return to work, 287 (41.5%) were unable to work and/or preferred not to work because of acute myocardial infarction and 131 (19.0%) retired early owing to the acute myocardial infarction. Female sex (relative risk, 0.65; 95% CI, 0.41-0.88), a history of smoking (relative risk, 0.82; 95% CI, 0.65-0.98), and in-hospital complications during the index acute myocardial infarction (relative risk, 0.96; 95% CI, 0.93-0.99) were associated with a lower likelihood of returning to work.

CONCLUSIONS AND RELEVANCE

Almost half of the previously employed Chinese patients did not return to work within 12 months after acute myocardial infarction. Female sex, history of smoking, and in-hospital complications were associated with a lower likelihood of returning to work.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01624909.

Common Psychosocial Factors Predicting Return to Work After Common Mental Disorders, Cardiovascular Diseases, and Cancers: A Review of Reviews Supporting a Cross-Disease Approach

Purpose This systematic review aimed at identifying the common psychosocial factors that facilitate or hinder the return to work (RTW) after a sick leave due to common mental disorders (CMDs), cardiovascular diseases (CVDs), or cancers (CAs). Methods We conducted a review of reviews searching 13 databases from 1994 to 2016 for peer-reviewed, quantitative, cohort studies investigating factors influencing RTW after a CMD, CVD, or CA. Then, for each disease we identified additional cohort studies published after the date of the latest review included. Data were extracted following a three steps best-evidence synthesis method: the extraction of results about each predictor from studies within each single review and in the additional papers; the synthesis of results across the reviews and additional papers investigating the same disease; and the synthesis of results across the diseases. Results The search strategy identified 1029 unique records from which 27 reviews and 75 additional studies underwent comprehensive review. 14 reviews and 32 additional cohort studies met eligibility criteria. Specific predictors of RTW with different levels of evidence are provided for each disease. We found four common facilitators of RTW (job control, work ability, perceived good health and high socioeconomic status), and six barriers of RTW (job strain, anxiety, depression, comorbidity, older age and low education). Conclusion This is the first review to systematically analyze commonalities in RTW after CMDs, CVDs, or CAs. The common factors identified indicate that the RTW process presents many similarities across various diseases, thus supporting the validity of a cross-disease approach.

[Sense of Coherence Scale according to Antonovsky as a possible predictor for return to work for cardiac surgery intensive care patients]

BACKGROUND

For cardiac surgery patients who were employed prior to surgery, the return to their professional life is of special importance. In addition to medical reasons, such as pre-existing conditions, the success of the operation or postoperative course and patient-intrinsic reasons, which can be assessed with the Sense of Coherence (SOC) scale by Antonovsky, may also play a role in the question of a possible return into working life.

METHODS

In this study 278 patients (invasive coronary artery bypass graft surgery and/or surgery on heart valves, age < 60 years, employed) were questioned postoperatively via post with the SOC questionnaire. The SOC questionnaire was used in addition to questions about return to work. The cohort was stratified according to the time of return to work. Subsequently, the point of maximum sensitivity and specificity was determined for the total SOC score and the prediction power was considered.

RESULTS

Of the 278 patients, 61 questionnaires (22%) were considered as eligible and included in the analysis. Of these, 47 participants had returned to work after undergoing cardiac surgery and 14 participants had not. We observed significant differences in SOC values between both groups (146.07 ± 29.76 versus 124.29 ± 28.8, p = 0.020). Patients that returned to work within the first 6 months after surgery showed even higher SOC scores (148.56 ± 28.98, p = 0.034).

CONCLUSION

Patients with an SOC score < 130 are at greater risk not to return to their professional life after cardiac surgery. The SOC is an easily obtainable score that reliably predicts the probability of return to work after cardiac surgery.

Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial

Background

Anxiety and depression are prevalent among cardiac rehabilitation patients but pharmacological and psychological treatments have limited effectiveness in this group. Furthermore, psychological interventions have not been systematically integrated into cardiac rehabilitation services despite being a strategic priority for the UK National Health Service. A promising new treatment, metacognitive therapy, may be well-suited to the needs of cardiac rehabilitation patients and has the potential to improve outcomes. It is based on the metacognitive model, which proposes that a thinking style dominated by rumination, worry and threat monitoring maintains emotional distress. Metacognitive therapy is highly effective at reducing this thinking style and alleviating anxiety and depression in mental health settings. This trial aims to evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy for cardiac rehabilitation patients with elevated anxiety and/or depressive symptoms.

Methods/Design

The PATHWAY Group-MCT trial is a multicentre, two-arm, single-blind, randomised controlled trial comparing the clinical- and cost-effectiveness of group-based metacognitive therapy plus usual cardiac rehabilitation to usual cardiac rehabilitation alone. Cardiac rehabilitation patients (target sample n = 332) with elevated anxiety and/or depressive symptoms will be recruited across five UK National Health Service Trusts. Participants randomised to the intervention arm will receive six weekly sessions of group-based metacognitive therapy delivered by either cardiac rehabilitation professionals or research nurses. The intervention and control groups will both be offered the usual cardiac rehabilitation programme within their Trust. The primary outcome is severity of anxiety and depressive symptoms at 4-month follow-up measured by the Hospital Anxiety and Depression Scale total score. Secondary outcomes are severity of anxiety/depression at 12-month follow-up, health-related quality of life, severity of post-traumatic stress symptoms and strength of metacognitive beliefs at 4- and 12-month follow-up. Qualitative interviews will help to develop an account of barriers and enablers to the effectiveness of the intervention.

Discussion

This trial will evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy in alleviating anxiety and depression in cardiac rehabilitation patients. The therapy, if effective, offers the potential to improve psychological wellbeing and quality of life in this large group of patients.

Trial registration

UK Clinical Trials Gateway, ISRCTN74643496, Registered on 8 April 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2593-8) contains supplementary material, which is available to authorized users.

Psychological sequelae of myocardial infarction

Patient with myocardial infarction (MI) are often affected by psychological disorders such as depression, anxiety, and post-traumatic stress disorder. Psychological disorders are disabling and have a negative influence on recovery, reduce the quality of life and causes high mortality rate in MI patients. Despite tremendous advancement in technologies, screening scales, and treatment strategies, psychological sequelae of MI are currently understudied, underestimated, underdiagnosed, and undertreated. Depression is highly prevalent in MI patients followed by anxiety and post-traumatic stress disorder. Pathophysiological factors involved in psychopathologies observed in patients with MI are sympathetic over-activity, hypothalamic-pituitary-adrenal axis dysfunction, and inflammation. Numerous preclinical and clinical studies evidenced a positive association between MI and psychopathologies with a common molecular pathophysiology. This review provides an update on diagnostic feature, prevalence, pathophysiology, clinical outcomes, and management strategies of psychopathologies associated with MI. Moreover, preclinical research findings on molecular mechanisms involved in post-MI psychopathologies and future therapeutic strategies have been outlined in the review.

The issue of "long-term" fit notes for depression in the UK: patient, GP and general practice variation

Background: Depression is an important cause of certified sickness absence in the UK. It is not known what factors are associated with variation in length of sickness certificates issued by the GP to the depressed patient.Aims: The purpose of the study was to identify patient, GP and practice factors associated with the issue of a long-term (> 4 week) fit note for depression.Methods: Sixty-eight UK general practices collected sickness certification data for 12 months.Results: Over 35% of 8127 fit notes issued to 3361 patients for depression were classed as long-term (over four weeks in duration). Having previous fit notes for depression, not having "may be fit" advice on the fit note, older patient age, the patient living in a deprived neighbourhood and a higher practice deprivation status were all significant predictors of a long-term fit note. Depression fit notes issued by female GPs to female patients were less likely to be long-term. Other GP factors were not significant predictors of a long-term depression note.Conclusions: Reducing the number of long-term sickness certificates issued to people with depression should be considered part of return-to work and job retention strategies.

Job demands and decision control predicted return to work: the rapid-RTW cohort study

Background

In order to help workers with long-term sickness absence return to work (RTW), it is important to understand factors that either impede or facilitate employee’s reintegration into the labour force. The aim of this study was therefore to examine the impact of psychological work characteristics on time-to first RTW in sick listed employees in Norway.

Methods

The study was designed as a cohort study of 543 employees participating in 50 different RTW programmes. The Job Content Questionnaire (JCQ) was used to gather information on the psychological work conditions. The participants were followed for up to 18 months after they started treatment in the RTW programme. Survival analyses were used to investigate the association between psychological work conditions and time-to first RTW.

Results

Having high psychological job demands (HR = .654; 95% CI: .513–.832) and low decision control (HR = 1.297; 95% CI: 1.010–1.666) were both independent predictors of delayed RTW. Employees in low-strain jobs (low demands/high control) (HR = 1.811; 95% CI: 1.287–2.549) and passive jobs (low demands/low control) (HR = 1.599; 95% CI: 1.107–2.309), returned to work earlier compared to employees in high-strain jobs (high demands/low control). No difference was found for active jobs (high demands/high control).

Conclusion

This study revealed that high psychological demands, low control, and being in a high strain job reduced the probability of early RTW in sick listed employees. RTW programmes should therefore increase the focus on these issues.

Return to work after coronary revascularization procedures and a patient's job satisfaction: A prospective study

INTRODUCTION

Research into work reintegration following invasive cardiac procedures is limited. The aim of this prospective study was to explore predictors of job satisfaction among cardiac patients who have returned to work after cardiac rehabilitation (CR).

MATERIAL AND METHODS

The study population consisted of 90 cardiac patients who have recently been treated with coronary angioplasty or heart surgery. They were evaluated during their CR and 12 months after the discharge using validated self-report questionnaires measuring job satisfaction, work stress-related factors, emotional distress and illness perception. Information on socio-demographic, medical and occupational factors has also been collected.

RESULTS

After adjusting for demographic, occupational and medical variables, baseline job satisfaction (p < 0.001), depression (p < 0.01) and ambition (p < 0.05) turned out to be independent, significant predictors of job satisfaction following return to work (RTW). Patients who had a partial RTW were more satisfied with their job than those who had a full RTW, controlling for baseline job satisfaction.

CONCLUSIONS

These findings recommend an early assessment of patients' psychosocial work environment and emotional distress, with particular emphasis on job satisfaction and depressive symptoms, in order to promote satisfying and healthy RTW after cardiac interventions.

Researching Complex and Multi-Level Workplace Factors Affecting Disability and Prolonged Sickness Absence

Purpose There is growing research evidence that workplace factors influence disability outcomes, but these variables reflect a variety of stakeholder perspectives, measurement tools, and methodologies. The goal of this article is to summarize existing research of workplace factors in relation to disability, compare this with employer discourse in the grey literature, and recommend future research priorities. Methods The authors participated in a year-long collaboration that ultimately led to an invited 3-day conference, "Improving Research of Employer Practices to Prevent Disability, held October 14-16, 2015, in Hopkinton, Massachusetts, USA. The collaboration included a topical review of the literature, group conference calls to identify key areas and challenges, drafting of initial documents, review of industry publications, and a conference presentation that included feedback from peer researchers and a question/answer session with a special panel of knowledge experts with direct employer experience. Results Predominant factors in the scientific literature were categorized as physical or psychosocial job demands, work organization and support, and workplace beliefs and attitudes. Employees experiencing musculoskeletal disorders in large organizations were the most frequently studied population. Research varied with respect to the basic unit of assessment (e.g., worker, supervisor, policy level) and whether assessments should be based on worker perceptions, written policies, or observable practices. The grey literature suggested that employers focus primarily on defining roles and responsibilities, standardizing management tools and procedures, being prompt and proactive, and attending to the individualized needs of workers. Industry publications reflected a high reliance of employers on a strict biomedical model in contrast to the more psychosocial framework that appears to guide research designs. Conclusion Assessing workplace factors at multiple levels, within small and medium-sized organizations, and at a more granular level may help to clarify generalizable concepts of organizational support that can be translated to specific employer strategies involving personnel, tools, and practices.

Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews

Background

Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research.

Objectives

To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes.

Methods

Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews.

Results

Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.

Conclusions

Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.

Job demand and control interventions: a stakeholder-centered best-evidence synthesis of systematic reviews on workplace disability

BACKGROUND

Physical and psychological job demands in combination with the degree of control a worker has over task completion, play an important role in reducing stress. Occupational stress is an important, modifiable factor affecting work disability. However, the effectiveness of reducing job demands or increasing job control remains unclear, particularly for outcomes of interest to employers, such as absenteeism or productivity.

OBJECTIVE

This systematic review reports on job demand and control interventions that impact absenteeism, productivity and financial outcomes.

METHODS

A stakeholder-centered best-evidence synthesis was conducted with researcher and stakeholder collaboration throughout. Databases and grey literature were searched for systematic reviews between 2000 and 2012: Medline, EMBASE, the Cochrane Database of Systematic Reviews, DARE, CINAHL, PsycINFO, TRIP, health-evidence.ca, Rehab+, National Rehabilitation Information Center (NARIC), and Institute for Work and Health. Articles were assessed independently by two researchers for inclusion criteria and methodological quality. Differences were resolved through consensus.

RESULTS

The search resulted in 3363 unique titles. After review of abstracts, 115 articles were retained for full-text review. 11 articles finally met the inclusion criteria and are summarized in this synthesis. The best level of evidence we found indicates that multimodal job demand reductions for either at-work or off-work workers will reduce disability-related absenteeism.

CONCLUSION

In general, the impacts of interventions that aim to reduce job demands or increase job control can be positive for the organization in terms of reducing absenteeism, increasing productivity and cost-effectiveness. However, more high quality research is needed to further assess the relationships and quantify effect sizes for the interventions and outcomes reviewed in this study.

Impact of health care system delay in patients with ST-elevation myocardial infarction on return to labor market and work retirement

System delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI.

The presence of a depressive episode predicts lower return to work rate after myocardial infarction

CONTEXT

No studies have evaluated whether the presence of a depressive episode is associated with an increased risk of not returning to work following myocardial infarction (MI).

OBJECTIVES

To examine the prospective associations between depressive episode and anxiety disorders with return to work (RTW) after MI at 3 and 12 months based on International Classification of Diseases, 10th Revision.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the North of The Netherlands.

PARTICIPANTS

From a sample of patients hospitalized for MI (n=487), we selected those who had a paid job at the time of the MI (N=200).

MAIN EXPOSURE MEASURES

Presence of a depressive episode and presence of any anxiety disorder during the first 3 months post-MI.

MAIN OUTCOME MEASURES

RTW at 12 months post-MI.

RESULTS

Of the patients with work prior to MI, 75% had returned to work at 12 months. The presence of a depressive episode during the first 3 months (prevalence: 19.4%) was a significant predictor of no RTW at 12 months post-MI, also after controlling for confounders [odds ratio (OR) 3.48; 95% confidence interval (CI): 1.45-8.37]. The presence of an anxiety disorder (prevalence: 11.9%) had a borderline significant association with no RTW as well. This association remained after controlling for confounders (OR 2.90; 95% CI: 1.00-6.38) but diminished when controlling for depression.

CONCLUSIONS

The presence of a depressive episode was associated with an increased risk of no RTW in MI patients. The association between anxiety and risk of no RTW could in part be explained by the presence of depression. Further studies may address the possibility of countering the effect of depression by effective treatment.

Perceived impeding factors for return-to-work after long-term sickness absence due to major depressive disorder: a concept mapping approach

Objective

The purpose of the present study was to explore various stakeholder perspectives regarding factors that impede return-to-work (RTW) after long-term sickness absence related to major depressive disorder (MDD).

Methods

Concept mapping was used to explore employees', supervisors' and occupational physicians' perspectives on these impeding factors.

Results

Nine perceived themes, grouped in three meta-clusters were found that might impede RTW: Person, (personality / coping problems, symptoms of depression and comorbid (health) problems, employee feels misunderstood, and resuming work too soon), Work (troublesome work situation, too little support at work, and too little guidance at work) and Healthcare (insufficient mental healthcare and insufficient care from occupational physician). All stakeholders regarded personality/coping problems and symptoms of depression as the most important impeding theme. In addition, supervisors emphasized the importance of mental healthcare underestimating the importance of the work environment, while occupational physicians stressed the importance of the lack of safety and support in the work environment.

Conclusions

In addition to the reduction of symptoms, more attention is needed on coping with depressive symptoms and personality problems in the work environment support in the work environment and for RTW in mental healthcare, to prevent long term sickness absence.

Evaluating the impact of depression, anxiety & autonomic function on health related quality of life, vocational functioning and health care utilisation in acute coronary syndrome patients: the ADVENT study protocol

BACKGROUND

Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome patients. Somatic and cognitive subtypes of depression and anxiety in acute coronary syndrome have been shown to be associated with mortality although their association with patient outcomes is unknown, as are the mechanisms that underpin these associations. We are conducting a prospective cohort study which aims to examine in acute coronary syndrome patients: (1) the role of somatic subtypes of depression and anxiety as predictors of health related quality of life outcomes; (2) how somatic subtypes of depression and anxiety relate to long term vocational functioning and healthcare utilisation; and (3) the role of the autonomic nervous system assessed by heart rate variability as a moderator of these associations.

METHODS

Patients are being screened after index admission for acute coronary syndrome at a single, high volume centre, MonashHeart, Monash Health, Victoria, Australia. The inclusion criterion is all patients aged > 21 years old and fluent in English admitted to MonashHeart, Monash Health with a diagnosis of acute coronary syndrome. The primary outcome is mean health related quality of life (Short Form-36) Physical and Mental Health Summary scores at 12 and 24 months in subtypes with somatic symptoms of depression and anxiety. Depressive domains are assessed by the Beck Depression Inventory II and the Cardiac Depression Scale. Anxiety is measured using the Speilberger State-Trait Anxiety Inventory and the Crown Crisp Phobic Anxiety questionnaire. Secondary outcomes include clinical variables, healthcare service utilisation and vocational functioning.

DISCUSSION

This manuscript presents the protocol for a prospective cohort study which will investigate the role of somatic subtypes of depression and anxiety as predictors of health related quality of life, long-term vocational functioning and health service use, and the role of the autonomic nervous system in moderating these associations. Findings from the study have the potential to inform more effective pharmacological, psychological and behavioural interventions and better guide health policy on the use of health care resources.

Role identity and the work role after myocardial infarction

This study was designed to determine the roles most salient for individuals following a myocardial infarction (MI) and identify relationships among worker demographics, depression, illness intrusion, role identity, and self-esteem. Thirty participants 18 years or older, paid employees working 20 or more hours per week immediately prior to the MI, receiving care at one of the identified clinics, able to read English, and having a diagnosis of an acute MI within the past year completed questionnaires regarding role identity, illness intrusion, self-esteem, and depression. The results demonstrated the work role was significant for individuals after an MI. In addition, participants felt their current occupation had much to do with how they felt about themselves. The correlation between being employed now and an individual's occupation supported the finding that workers value their work role.

Indirect costs in patients with coronary artery disease and mental disorders: a systematic review and meta-analysis

OBJECTIVES

The aim of the present study was to systematically review the association of comorbid mental disorders with indirect health care costs in patients with coronary artery disease (CAD).

MATERIALS AND METHODS

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included, which allowed for a comparison of indirect health care costs between CAD patients with comorbid mental disorders and CAD patients without mental disorders.

RESULTS

The literature search revealed 4962 potentially relevant studies, out of which 13 primary studies met the inclusion criteria. Depression was investigated most often (N = 10), followed by anxiety disorders (N = 3) and any mental disorder not further specified (N = 3). All studies focused on return to work as indirect cost outcome. CAD patients with depression showed diminished odds for return to work, compared to CAD patients without depression (OR = 0.37; 95% CI: 0.27-0.51). The findings for comorbid anxiety and any mental disorder were inconsistent. Indirect health care costs were exclusively assessed by a patient self-report (N = 13).

CONCLUSIONS

There is strong evidence for diminished odds of return to work in CAD patients with comorbid depression, highlighting the need for integrated CAD and depression care. With regard to other comorbid mental disorders, however, the evidence is sparse and inconclusive.

Returning to paid employment after stroke: the Psychosocial Outcomes In StrokE (POISE) cohort study

OBJECTIVES

To determine which early modifiable factors are associated with younger stroke survivors' ability to return to paid work in a cohort study with 12-months of follow-up conducted in 20 stroke units in the Stroke Services NSW clinical network.

PARTICIPANTS

Were aged >17 and <65 years, recent (within 28 days) stroke, able to speak English sufficiently to respond to study questions, and able to provide written informed consent. Participants with language or cognitive impairment were eligible to participate if their proxy provided consent and completed assessments on the participants' behalf. The main outcome measure was return to paid work during the 12 months following stroke.

RESULTS

Of 441 consented participants (average age 52 years, 68% male, 83% with ischemic stroke), 218 were in paid full-time and 53 in paid part-time work immediately before their stroke, of whom 202 (75%) returned to paid part- or full-time work within 12 months. Being male, female without a prior activity restricting illness, younger, independent in activities of daily living (ADL) at 28 days after stroke, and having private health insurance was associated with return to paid work, following adjustment for other illnesses and a history of depression before stroke (C statistic 0·81). Work stress and post stroke depression showed no such independent association.

CONCLUSIONS

Given that independence in ADL is the strongest predictor of return to paid work within 12 months of stroke, these data reinforce the importance of reducing stroke-related disability and increasing independence for younger stroke survivors.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ANZCTRN 12608000459325.

The impact of gender on early ill-health retirement in people with heart disease and depression

OBJECTIVE

Depression and heart disease are major causes of early ill-health retirement. The effect of comorbid depression on the award of ill-health retirement in those with heart disease is unclear, however, and may differ by gender. Given the deleterious effects of ill-health retirement, identifying at-risk groups is important for guiding targeted interventions.

METHOD

We retrospectively analysed baseline data of 20,655 participants from the 45 and Up Study (New South Wales, Australia), who had fully retired between the ages of 45 and 64. We examined the associations of depression and heart disease with ill-health retirement and then adjusted for the presence of common confounders. We then restricted the sample to the 1165 individuals with heart disease prior to retirement, to determine the impact of comorbid depression on IHR and analysed whether there was a differential impact by gender.

RESULTS

In the complete sample, 3836 out of 20,655 (18.6%) of the participants retired early due to ill health. Prior heart disease and depression were both independently and strongly associated with ill-health retirement. Those who retired due to ill health were also more likely to be men, less educated, report greater physical disability and were younger at retirement. Among the 1165 for whom heart disease predated any form of retirement, 40% retired due to ill health. Comorbid depression prior to ill-health retirement was strongly associated with an increased risk of this IHR in women (odds ratio = 2.85; 95% confidence interval = 1.20-6.77, p = 0.01), but not in men (interaction term, p = 0.045).

CONCLUSIONS

Ill-health retirement is common in those with heart disease. Women appear to be particularly susceptible to the effects of comorbid depression. Given the policy emphasis on reducing the number of people leaving the workforce early, women with early heart disease may represent a particular group in whom interventions designed to detect and treat comorbid depression should be targeted.

Return to work after sick leave due to depression; a conceptual analysis based on perspectives of patients, supervisors and occupational physicians

OBJECTIVES

This study aims to investigate the most important factors facilitating a return to work after sick leave due to depression from the perspectives of patients, supervisors and occupational physicians.

METHODS

Concept mapping was used to develop a conceptual framework. Using purposive sampling, 32 participants representing Employees, supervisors and occupational physicians, were asked to formulate statements on what enables patients with sick leave due to depression to return to work. A total of 41 participants rated and grouped the statements. Data were analyzed using the statistical program Ariadne.

RESULTS

The concept mapping yielded 60 statements that consisted of promoting factors for return to work. Based on these statements, three meta-clusters and eight clusters were identified. The three meta-clusters consisted of work-related, person-related and healthcare- related clusters. The work-related meta-cluster comprised of "Adaptation of work", "Understanding and support in the workplace" and "Positive work experiences". The person- related meta-cluster encompassed "Positive and valid self-perception", "Competence in self management", "Positive level of energy", and "Balanced home/work environment". The healthcare-related meta-cluster was composed of "Supportive healthcare". Stakeholder groups differ in opinion, in what they see as most important for return to work.

LIMITATIONS

The low number of participants and the high educational level of participants are a limitation for generalization of the findings.

CONCLUSIONS

The study generated different statements that stakeholders consider important for return to work after sick leave due to depression. These findings can be used as a checklist for coordination of the return to work process. Differences in opinion regarding what stakeholders see as most important for return to work should receive special consideration during the re-integration process.