Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of depression and anxiety (the Danish IBBIS trial): study protocol for a randomized controlled trial

Effects of panic-specific cognitive behavioural and psychodynamic psychotherapies on work ability in a doubly randomised clinical trial

Objective: The effects of panic-specific psychotherapy on occupational functioning remain under-researched. This study tests whether two brief psychotherapies for Panic Disorder with or without Agoraphobia (PD/A) may generate improvement in work ability. Methods: Adults (N = 221) with a primary diagnosis of PD/A were randomised to wait-list, panic-focused psychodynamic psychotherapy (PFPP), panic control treatment (PCT), or to the choice between the two treatments. Participants completed the Work Ability Inventory (WAI) at baseline, post-treatment, and during 24-month follow-ups. Change in WAI scores were assessed using segmented multilevel linear growth models, and mediation was explored through path analysis. Results: WAI scores changed from the moderate to good range between baseline and post-treatment (SMD = 0.45; 95% CI [0.33, 0.57]) and continued to increase throughout the follow-up (SMD = 0.16; 95% CI [0.03, 0.28]) with no differences between treatments or allocation forms. In PFPP (but not in PCT) pre- to post-treatment change in WAI was mediated by reduction in panic symptoms and WAI predicted employment status and absences. Conclusions: Two brief panic specific psychotherapies, one cognitive behavioural and one psychodynamic, produced short and long-term increases in work ability.

Predictors of return to work for people on sick leave with depression, anxiety and stress: secondary analysis from a randomized controlled trial

PURPOSE

Knowledge about predictors of return to work (RTW) in people on sick leave with common mental disorders (CMDs) may inform the development of effective vocational rehabilitation interventions for this target group. In this study, we investigated predictors of RTW at 6 and 12 months in people on sick leave with depression, anxiety disorders or stress-related disorders.

METHODS

We have performed a secondary analysis, utilizing data from two RCTs that evaluated the efficacy of an integrated health care and vocational rehabilitation intervention. Data were obtained from mental health assessments, questionnaires and registers. Using Cox regression analysis, the relationship between baseline variables and RTW was analysed at 6 and 12 months after randomization within the group of CMD as a whole and within the subgroups of depression, anxiety and stress-related disorders.

RESULTS

Symptom burden and employment status at baseline predicted RTW in the CMD group (n = 1245) and in the three diagnostic subgroups at both time points. RTW self-efficacy predicted RTW in the depression group but not in the anxiety or stress subgroups.

CONCLUSION

Many predictors of RTW were similar over time and, to some extent, across the CMD subgroups. Findings highlight the need not only to take health-related and psychological factors into account when developing vocational rehabilitation interventions but also to consider workplace strategies and options for support.

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.

Integrated mental health care and vocational rehabilitation intervention to improve return to work rates for people on sick leave due to common mental and functional disorders (IBBIS-II)-a study protocol for a randomized clinical trial

BACKGROUND

Mental illness has an estimated financial burden on the Danish economy of 3.4% of the gross national product every year due to lost productivity, social benefits, and healthcare costs, and approximately 50% of people receiving long-term sickness benefits have a common mental illness. Furthermore, a significant treatment gap exists where less than 30% are treated for their mental illness. The primary objective of the randomized trial is to examine whether people on sick leave with a diagnosis of anxiety, depression, stress, personality disorders, or functional disorders return to work faster and have higher job retention if they receive an integrated and optimized vocational rehabilitation and mental health care intervention, compared to people who receive the standard mental health care and vocational rehabilitation service.

METHODS

The trial is designed as an investigator-initiated, randomized, two-group parallel, assessor-blinded, superior trial. A total of 900 participants with a common mental illness will randomly be assigned into two groups: (1) IBBIS-II, consisting of integrated mental health care and vocational rehabilitation, or (2) service as usual (SAU), at two sites in Denmark. The primary outcome is the difference between the two groups in time to return to work (RTW) at 12 months using data from the Danish Register for Evaluation of Marginalization (DREAM) database.

DISCUSSION

This study will contribute with new knowledge on vocational recovery and integrated vocational and health care interventions in a Scandinavian context.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04432129 . Registered on June 16, 2020.

Depression and loneliness may predict work inefficiency among professionally active adults

Purpose

Both depression and loneliness have been recognized as major public health issues, yet investigation into their role among young and middle-aged, professionally active persons is still required. The aim of the present study was to evaluate whether depression and loneliness may independently predict inefficiency at work among professionally active adults.

Methods

This is a cross-sectional study on a representative, nationwide sample. 1795 questionnaires were gathered from among professionally active adults from Poland from 1 to 31 July 2018 with a direct pen-and-paper interview. The sample was chosen by means of the stratified random method. The survey included a Patient Health Questionnaire (PHQ-9) to measure depression and questions, devised by the authors, relating to loneliness and inefficiency at work. Regression models were constructed with depression and loneliness as predictors of inefficiency at work, unadjusted and adjusted for selected sociodemographic, health- and work-related factors.

Results

In the unadjusted models, both depression and loneliness were independently associated with an increase of work inefficiency and absence from work, with effect sizes being higher for loneliness than for depression. After accounting for the control variables (i.e., sociodemographic, work- and health-related factors), the PHQ-9 score, but not the loneliness score, was associated with an increased probability of frequent thoughts about changing or leaving a job.

Conclusion

Depression and loneliness independently predicted occupational functioning and differentially affect its various aspects. Counteracting depression and loneliness among employees should be regarded as a public health priority.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01869-1.

Predictors of return to work for people on sick leave with common mental disorders: a systematic review and meta-analysis

PURPOSE

To support the return to work following common mental disorders knowing which factors influence the return to work is important. We aimed to identify factors predicting return to work for people on sick leave with disorders like stress, anxiety, and depression.

METHODS

A systematic review and meta-analyses were conducted regarding return to work at any time point, < 3 months, 3-12 months, and > 12 months of sick leave, respectively, and diagnostic subgroups.

RESULTS

The meta-analyses included 29 studies. Predictors decreasing return to work probability at any time point were higher age, being male, neuroticism and openness, previous sickness absence, and higher symptom scores. Predictors increasing return to work probability were positive return to work expectations, high return to work- and general self-efficacy, conscientiousness, and high workability index. Return to work within < 3 months of sick leave was associated with positive return to work expectations. Return to work after > 12 months was increased by higher education. Higher age was associated with decreased return to work probability after > 12 months. No significant predictors were found in diagnostic subgroups.

CONCLUSION

Results are overall consistent with earlier reviews. Future studies should focus on specific time points, diagnostic subgroups, and work-related factors.

PROSPERO REGISTRATION ID

CRD42018073396.

Developing Interpersonal Trust Between Service Users and Professionals in Integrated Services: Compensating for Latent Distrust, Vulnerabilities and Uncertainty Shaped by Organisational Context

Introduction:

Studies show a need for trust between stakeholders in integrated services. However, few studies have investigated how trust develops between stakeholders on a micro-level. In a Danish intersectoral intervention for persons on sick leave due to common mental disorders, we explored why trust is needed and how trust is developed between micro-level stakeholders.

Methodology:

The qualitative study was based on 12 observations of inter-organisational meetings, 16 interviews with service users, 24 interviews with health care professionals and employment consultants, and 8 interviews with supervisors. The analysis was guided by the theoretical concepts (dis-) trust, vulnerability and uncertainty.

Results:

Latent distrust between involved organisations, and vulnerabilities and uncertainties related to employment consultants’ statutory power over service users caused a perceived need for interpersonal trust. Time to establish knowledge-based relationships, healthcare professionals’ caring approach, and creating a feeling of sharing interests were compensating trust-building strategies that were often regarded as positive.

Discussion and conclusion:

Trust in personal relationships between stakeholders appeared to compensate for contextually shaped distrust, vulnerability and uncertainty. Identifying latent distrust, vulnerabilities, uncertainties, and power structures might be key to improving trust-building strategies in a specific context. The time-consuming process of trust-building between micro-level stakeholders should be supported structurally.

Can high workplace social capital buffer the negative effect of high workload on patient-initiated violence? Prospective cohort study

BACKGROUND

High workload seems to increase the risk of patient-initiated workplace violence (patient-initiated violence). However, the temporal association between workload and violence remains uncertain. Understanding the interplay of factors in the psychosocial working environment and patient-initiated violence is important to future preventive initiatives.

AIM

To assess whether a high workload increases the risk of patient-initiated violence, and whether intraorganizational relationships based on trust, reciprocity, justice and collaboration, known as workplace social capital, moderate this risk.

METHOD

Baseline survey data on 1823 social educators was collected followed by 12 monthly surveys on patient-initiated violence exposure. Poisson regressions, in mixed models, were conducted to assess the risk of violence at four levels of workload. Further, moderation analyses were conducted to assess the moderating effects of three sub-types of workplace social capital.

RESULTS

High and very high workload increased the risk of patient-initiated violence: RR = 1.5 [1.4-1.6], p < .001 and RR = 1.4 [1.3-1.4], p < .001. All three levels of workplace social capital had a moderating effect on the workload-violence association: Workload*Workplace social capital_(co-worker): F (3, 16,712) = 3.4, p = .017, Workload*Workplace social capital_{(local management)}: F (3, 16,748) = 11.9, p < .001, Workload*Workplace social capital_{(general management)}: F (3, 16,556) = 5.5, p < .001. Only high Workplace social capital _(co-workers) reduced the risk of violence at all levels of workload. Workplace social capital _{(general management)} reduced the risk of violence at high, medium and low workload, and Workplace social capital _{(local management)} reduced the risk of violence at medium and low workload.

CONCLUSION

High workload clearly increases the risk of patient-initiated violence. A high workplace social capital appears to be a viable protective factor and should be investigated further in studies of patient-initiated violence prevention.

Factors Associated With Time to Achieve Employment Through Occupational Support Programs in Patients With Mood Disorders: 1 Year Naturalistic Study

Objective: Mood disorders cause significant work performance disability in sufferers and often lead to adverse employment outcomes in working individuals. The aim of this study was to explore factors associated with time to achieve employment through the occupational support program (OSP) for patients with mood disorders. Methods: The participants were patients admitted to the Kyorin university hospital from April 2016 to April 2019. Patients who met the criteria for major depressive disorder and depressive episode of bipolar I or II disorder according to DSM-5 and participated in the occupational therapy-based OSP for at least three sessions (one course) were included in this study. We collected demographic and clinical variables at the baseline of this study through medical records and OSP records; the variables included age, gender, diagnosis, scores of Quick Inventory of Depressive Symptomatology and Global Assessment of Functioning, the number of times of participation in the OSP, word count of the transcription task in the OSP, typographical deficiency, fatigue status and mood status after the OSP. The primary outcome was set as the time to achieve the employment within 1 year after the discharge. Results: Of the 211 patients who participated in the OSP during the survey period, 49 participants met the criteria in this study. The results showed that 14 patients achieved and the other 35 patients did not achieve the employment within 1 year of discharge from the hospital. A multivariate cox regression analysis revealed that the word count of the transcription task in the OSP (HR = 1.03, 95% CI = 1.01-1.05, p = 0.016) and mood status after the OSP (HR = 2.77, 95% CI = 1.18-6.51, p = 0.019) were significantly associated with time to achieve the employment. Conclusion: In conclusion, this study suggested that work speed and mood response in the OSP could be significant predictors for achieving employment in patients with mood disorders.

[Return to Work after Mental Disorders - A Scoping Review]

OBJECTIVE

Workers on sick-leave due to a mental disorder have enormous problems to return to work. The main objective of this review is to examine different return-to-work (RTW) interventions.

METHODS

We conduct a systematic literature research.

RESULTS

88 articles were screened and 29 studies included. The included RTW-interventions build on different approaches: 1) individual, 2) workplace, 3) mental health services. The majority of the interventions showed positive effects on the return-to-work process.

CONCLUSION

Even if not all interventions could be readily transferred to the German context, the findings indicate ways improving the transition from the mental health system to the workplace.

Shared Decision Making in an Integrated Mental Health and Vocational Rehabilitation Intervention: Stakeholder Practices and Experiences

Introduction

A Danish integrated mental health care and vocational intervention was developed to support the return-to-work process for people with common mental disorders. Shared decision making was a core element of the intervention to ensure a person-centred approach. The study aim is to describe how shared decision making was practiced and experienced and to discuss its potential in this integrated care context.

Theory and methods

Shared decision making practice and experience was studied in participant observation (n = 20), interviews (n = 12), focus groups interviews (n = 2), and shared plan documents (n = 12). Research methods and analyses were guided by theoretically defined ideals of shared decision making.

Results

Shared decision making constituted a general value rather than a structured method in practice. Clients experienced a more person-centred collaboration with professionals, compared to the regular vocational system. Contextual factors regarding vocational legislation and the intervention design influenced the decision latitude.

Conclusion

Shared decision making has the potential to support a person-centred approach in integrated services. However, we recommend clarifying decisions applicable for shared decision making, to ensure thorough training, develop and test decision aids, and ensure supportive organisational conditions for shared decision making in interprofessional collaboration.

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.

Assessing measurement equivalence of the Danish and Dutch Four-Dimensional Symptom Questionnaire using differential item and test functioning analysis

Aims: The Dutch Four-Dimensional Symptom Questionnaire (4DSQ) measures distress, depression, anxiety and somatisation, facilitating the distinction between stress-related problems and psychiatric disorder in primary and occupational health care. The aim of the study was to examine the measurement equivalence across the Danish and Dutch 4DSQ. Methods: Danish 4DSQ data were obtained from a cohort of Danish citizens on sick leave for mental-health problems. Dutch 4DSQ data were obtained from a cohort of Dutch employees on sick leave and a cohort of general practice attenders suspected of having mental-health problems. The study samples were matched on age and sex. The 4DSQ scales were assessed for essential unidimensionality using confirmatory factor analysis. Measurement equivalence of the 4DSQ across the groups was assessed using differential item and test functioning (DIF and DTF) analysis. Results: The study groups each consisted of 1363 people (63% female, M_age=42 years). The 4DSQ scales proved essentially unidimensional. DIF was detected in 20 items. In terms of Cohen’s effect size, DIF was mostly small or moderate. In terms of effect size, the mean effect on the scale score (DTF) was negligible. Nevertheless, it is recommended to adjust some of the cut-off points for two Danish 4DSQ scales to retain the meaning of these cut-off points in Dutch respondents. Conclusions:The Danish version of the 4DSQ measures the same constructs as the original Dutch questionnaire. Twenty items functioned differently in Danish respondents than in Dutch respondents, but this had only a small impact on the scale scores.

Developing Normative Integration among Professionals in an Intersectoral Collaboration: A Multi-Method Investigation of an Integrated Intervention for People on Sick Leave Due to Common Mental Disorders

Introduction:

Intersectoral integration is recommended in vocational rehabilitation, though difficult to implement. We describe barriers to and strategies for the development of normative integration in an intersectoral, team-based vocational rehabilitation intervention.

Method:

Attitudes and behaviours regarding the development of shared culture, norms, and goals in the collaboration between health care professionals and employment consultants were investigated through 30 semi-structured interviews, participant observation of 12 intersectoral meetings, and document analysis of 12 joint plans.

Results:

Organisational factors and unsettled power balance between professionals constituted barriers to the development of a shared culture. These issues were resolved by establishing smaller work teams, and through health care professionals’ gradual acceptance of employment consultants’ control in their capacity as administrators of legislation. Some barriers to shared norms were resolved explicitly, whereas implicit diverging norms were continuously negotiated. The development of shared goals was supported by clarifying the fit between individual, professional, and organisational goals, though the alignment of goals required a paradigmatic change of mindset among the health care professionals.

Conclusion:

This study shows how normative integration among health care professionals and employment consultants is feasible in co-located intersectoral teams, with positive implications for the delivery of coherent support.