Work-focused therapy for common mental disorders: A naturalistic study comparing an intervention group with a waitlist control group

Changes in memory and attention during and after occupational rehabilitation: A longitudinal study

BACKGROUND

There is need for more knowledge about the relationship between work and cognitive functioning in sick-listed individuals.

OBJECTIVE

This study investigated whether the degree of work participation is relevant for recovery of cognitive functioning in sick-listed individuals.

METHODS

177 occupational rehabilitation participants and 70 controls participated in a non-randomised, longitudinal study. Participants completed computerised cognitive tests targeting sustained attention and working memory at start and end of rehabilitation and 3 and 12 months after rehabilitation. The change score performance in attention and memory between start and end, start and 3 months and 12 months was compared in individuals on sick leave 100-75%, 74-40% and 39-0% (three sick leave groups) of the time in the year after rehabilitation, and a control group not being on sick leave. Fixed effect analysis of covariance adjusting for education and work ability was used.

RESULTS

The sick leave group 100-75% had significantly lower score on work ability compared to the other groups at baseline. The main findings indicated that the sick leave group 39-0% improved significantly more in sustained attention compared to the sick leave group 100-75% between start and end of rehabilitation and from start of rehabilitation to 3 and 12 months after.

CONCLUSION

The degree of work participation seems relevant to recovery of the cognitive function sustained attention in sick-listed individuals. These findings encourage work rehabilitation clinicians, work consultants and employers to develop RTW plans which take into account that graded employment influence cognitive functioning.

Defining work-focused cognitive behavioural therapy (W-CBT) and whether it is effective at facilitating return to work for people experiencing mental health conditions: A systematic review and narrative synthesis

It is unclear what constitutes Work Focused Cognitive Behaviour Therapy (W-CBT). This review sought to define W-CBT and ascertain its effectiveness at facilitating return to work (RTW) for people experiencing mental health conditions. A systematic review and narrative synthesis were undertaken. Five databases were searched (Medline, ProQuest, PsychInfo, Scopus, and Web of Science). English publications with an intervention combining CBT with RTW were selected. Quality checklists from the Joanna Briggs Institute were applied. Searching yielded 16,863 results. 23 moderate-to-high quality studies from 25 articles were included (13 experimentally designed studies, 3 pilots/case studies and 7 reviews). Results indicated W-CBT is effective at facilitating RTW for mild-to-moderate mental health conditions. For a program to be labelled W-CBT it is recommended it is (1) a stand-alone intervention; (2) delivered with an understanding RTW is the goal; and, (3) the CBT components are always framed by matters, subjects and contexts related to work.

Responsiveness to change in health status of the EQ-5D in patients treated for depression and anxiety

BACKGROUND

The EQ-5D is a commonly used generic measure of health but evidence on its responsiveness to change in mental health is limited. This study aimed to explore the responsiveness of the five-level version of the instrument, the EQ-5D-5 L, in patients receiving treatment for depression and anxiety.

METHODS

Patient data (N = 416) were collected at baseline and at end of treatment in an observational study in a Norwegian outpatient clinic. Patients were adults of working age (18-69 years) and received protocol-based metacognitive or cognitive therapy for depression or anxiety according to diagnosis. Responsiveness in the EQ-5D was compared to change in the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). Effect sizes (Cohen's d), Standardised response mean (SRM), and Pearson's correlation were calculated. Patients were classified as "Recovered", "Improved", or "Unchanged" during treatment using the BDI-II and the BAI. ROC analyses determined whether the EQ-5D could correctly classify patient outcomes.

RESULTS

Effect sizes were large for the BAI, the BDI-II, the EQ-5D value and the EQ VAS, ranging from d = 1.07 to d = 1.84. SRM were also large (0.93-1.67). Pearson's correlation showed strong agreement between change scores of the EQ-5D value and the BDI-II (r_s -0.54) and moderate between the EQ-5D value and the BAI (r_s -0.43). The EQ-5D consistently identified "Recovered" patients versus "Improved" or "Unchanged" in the ROC analyses with AUROC ranging from 0.72 to 0.84.

CONCLUSION

The EQ-5D showed good agreement with self-reported symptom change in depression and anxiety, and correctly identified recovered patients. These findings indicate that the EQ-5D may be appropriately responsive to change in patients with depression and anxiety disorders, although replication in other clinical samples is needed.

Recovery expectations can be assessed with single-item measures: findings of a systematic review and meta-analysis on the role of recovery expectations on return-to-work outcomes after musculoskeletal pain conditions

ABSTRACT

The objective of this systematic review is to quantify the association between recovery expectations and return-to-work outcomes in adults with musculoskeletal pain conditions. In addition, this review has the second objective to compare the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Relevant articles were selected from Embase, PsycINFO, PubMed, Cochrane, and manual searches. Studies that assessed recovery expectations as predictors of return-to-work outcomes in adults with musculoskeletal pain conditions were eligible. Data were extracted on study characteristics, recovery expectations, return-to-work outcomes, and the quantitative association between recovery expectations and return-to-work outcomes. Risk of bias was assessed using the Effective Public Health Practice Project. Odds ratios were pooled to examine the effects of recovery expectations on return-to-work outcomes. Chi-square analyses compared the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Thirty studies on a total of 28,741 individuals with musculoskeletal pain conditions were included in this review. The odds of being work disabled at follow-up were twice as high in individuals with low recovery expectations (OR = 2.06 [95% CI 1.20-2.92] P < 0.001). Analyses also revealed no significant differences in the predictive value of validated and nonvalidated single-item measures of recovery expectations on work disability (χ 2 = 1.68, P = 0.19). There is strong evidence that recovery expectations are associated with return-to-work outcomes. The results suggest that single-item measures of recovery expectations can validly be used to predict return-to-work outcomes in individuals with musculoskeletal pain conditions.

An assessment of workplace wellness policies and programs of universities in the Asia-Pacific

BACKGROUND

Universities could positively impact the health and well-being of employees through workplace wellness programs (WWP).

OBJECTIVE

To assess the prevalence of WWP among Asia-Pacific universities, identify gaps and challenges, and solutions to challenges.

METHODS

An online survey was sent to members of the Association of Pacific Rim Universities to assess programs on physical fitness, nutrition/weight, mental health/stress, family support, chronic disease prevention, and safety.

RESULTS

Employees at 28 universities in 13 economies completed the survey on behalf of their university. Most common WWP were paid maternity/paternity leave (89.3% /85.7%), disaster preparedness training (85.7%), fitness challenges (78.6%), written policies regarding discrimination/hate speech (75.0%), and quiet rest areas (71.4%). However, few addressed childcare, breastfeeding support, workplace sexual harassment, tobacco use, or mental health. Programs rarely aligned with the reported goal of increasing employee morale, but instead resulted from government mandates. Many universities offered sporadic, one-off programs but lacked comprehensive, coordinated programming and adequate evaluation procedures. Key challenges were low employee participation, limited budget, and lack of leadership support. This study highlights the need for improved program administration, information dissemination, data collection to evaluate impact, and leadership support.

CONCLUSION

WWP could benefit universities and employees but should be implemented and evaluated as part of a comprehensive campus wellness culture.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Healing the wounds of workplace bullying: Evaluating mental health and workplace participation among victims seeking treatment for common mental disorders

BACKGROUND

Victims of workplace bullying represent a group characterised by severe negative health complaints at risk of losing their foothold in working life. To date, very few studies have investigated the effect of psychological treatment of the health-related problems often facing victims of bullying.

OBJECTIVE

The aim was to investigate if victims of workplace bullying suffering from common mental disorders (CMD) benefit from clinical treatment for their mental health problems at an outpatient clinic treating patients using Metacognitive or Cognitive Behavioural Therapy with work-focus. Criteria were symptom reduction and change in workplace participation. Comparisons were made between the victims of workplace bullying with CMD, a wait-list control group consisting of patients who had also been exposed to bullying yet now awaiting treatment, and other patients not exposed to bullying.

METHODS

The sample comprised of 405 patients from an outpatient clinic in Norway. The study used a naturalistic observational design and data was collected pre-treatment and post-treatment.

RESULTS

The results showed the treatment to be effective in symptom reduction for victims of bullying to a similar degree as patients otherwise not exposed to bullying. Even more, victims receiving treatment had a larger improvement compared to the wait-list control group (p < 0.001). Yet, among patients on sick leave pre-treatment, fewer victims of bullying were fully working by the end of treatment compared to the patients not exposed to workplace bullying.

CONCLUSION

The findings provide ground for optimism for this treatment as an efficient way of dealing with the aftermath of workplace bullying.

Work after mental-health-related absence: a qualitative study of perceived change after a combination of metacognitive therapy and work-focused interventions

BACKGROUND

Sick leave caused by common mental health disorders (CMD) is becoming more prevalent. For most people, work is essential for good mental and physical health. It is necessary to provide treatments that facilitate return to work (RTW) and a reduction of symptoms. A qualitative study can contribute to an understanding of what makes an intervention successful. The aim of this study was to investigate how individuals who are on sick leave because of CMD perceive and handle their symptoms and their work, after completing metacognitive therapy and work-focused interventions.

METHODS

Semi-structured interviews were conducted with 23 participants after they had completed therapy. Thematic analysis was used to analyse the data.

RESULTS

Through both therapy and the process of RTW, the participants had gained increased awareness and understanding of their mental health problems and the relationship between those problems and work. Together with the sense that they were in charge of their own process of RTW, this helped to improve their self-confidence. An important part of the process was the change to new strategies and the rejection of older maladaptive ones, in relation to both mental health and work. Being open about their mental illness in the workplace could lead to support but also to the opposite, and therefore not an option for everyone. After treatment, most had returned to work and gained a more positive outlook on the future, but some had less confidence in their ability to deal with future symptoms and workplace issues.

CONCLUSIONS

Achieving improved self-confidence and adopting new strategies, which enabled them to change how they related to their mental problems and how they addressed their problems at work, seemed to have increased their self-efficacy. Active involvement in therapy and at work was also important, both for the process and as a way of increasing self-efficacy. This gave them renewed belief in themselves and in their ability to handle their work at present and in the future. Despite this being a manualized treatment, the participants' experience was that it was adapted to each individual, something they regarded as important.

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

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

Understanding the role and importance of occupational therapy in mental health services in Morocco: Perspectives from mental health professionals

BACKGROUND: Across the global landscape, mental health care still exhibits challenges because of the lack of human and professional resources to face its consequences. In Morocco, mental health problems affect mainly adolescents and young adults, with a clear impact on functional engagement in their daily lives. Occupational therapy, as a holistic and person-centered practice, may be an ideal mental health strategy to promote health and well-being through occupation, thereby enabling individuals to participate in regular daily activities. OBJECTIVE: To understand, from an intercultural perspective, the point of view of mental health professionals regarding the role and importance of occupation-based practices in Errazi Mental Health Hospital in Salé(Rabat) Morocco. METHOD: A qualitative research design was used for this study. Data collection consisted of semi-structured interviews with 12 mental health care professionals (non-occupational therapists). These results were used to gain an understanding of their perspectives regarding the main role of human occupation in mental health services in Morocco, and to incorporate an intercultural outlook in terms of occupational therapy. Data analysis was conducted in three phases, by following the grounded theory methodology. RESULTS: Two categories, “dimensions of occupation in Moroccan mental health” and “the interplay between traditional and western perspectives involving mental health” emerged from this research. Both categories included five subcategories. CONCLUSION: This study identifies how occupation-based services in Moroccan mental health care require considering not only the cultural perspective of mental health, and the sociocultural meaning rooted in occupations, but also the relevance of incorporating a community-centered approach. Moreover, it discusses how occupational therapy education in Morocco must incorporate an intercultural perspective of the therapy’s theory and practice.

Metacognitive therapy and work-focused interventions for patients on sick leave due to anxiety and depression: study protocol for a randomised controlled wait-list trial

BACKGROUND

Common mental disorders such as depression and anxiety are major contributors to the global burden of disease. Affected individuals suffer reduced quality of life, impaired functioning and reduced capacity to work. Maintaining employment is an important determinant for health and wellbeing, and the economic impact of depression and anxiety is a significant societal expense. Treatments providing effective symptom reduction and helping patients return to work (RTW) would thus have substantial public health benefits. The present study will explore the effectiveness of metacognitive therapy (MCT) and work-focused interventions on reducing symptoms and increasing RTW rates for patients on sick leave due to depression and anxiety.

METHODS

The study is a randomised controlled wait-list trial (RCT; N = 240). The intervention group will receive protocol-based MCT and work-focused interventions immediately after inclusion. The control condition is a wait-list control group. All patients will receive up to 12 weekly sessions. The study context is a Norwegian outpatient clinic part of a national programme aimed at reducing sick leave. The co-primary outcomes are change in RTW and symptoms of depression and anxiety at the end of treatment. In addition to self-report, sick leave will also be collected from national registries from 2 years prior to intervention to 4 years after intervention. Symptoms of scores will be collected by self-report at pre- and post-treatment and at 6 and 12 months follow-up after treatment. A cost-effectiveness analysis will use total cost and quality-adjusted life-years as the secondary outcomes.

DISCUSSION

There is broad consensus on the importance of identifying treatment that effectively reduces depression and anxiety symptoms and aids RTW. This study is an important contribution to the field as it is the first RCT on MCT and work-focused interventions for patients on sick leave due to anxiety and depression.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03301922 . Registered on October 4, 2017.

Self-Reported Health in Patients on or at Risk of Sick Leave Due to Depression and Anxiety: Validity of the EQ-5D

Objectives: The EQ-5D is a generic, self-report measure of health that is increasingly used in clinical settings, including mental health. The EQ-5D captures health using five dimensions: Mobility, Self-care, Usual activities, Pain/discomfort, and Anxiety/Depression. The validity of the EQ-5D is previously unexplored in patients on or at risk of sick leave due to depression and anxiety. The study’s aim was to examine its validity in this group of patients.

Methods: Baseline data were collected from self-report questionnaires in an observational study (N=890) at a Norwegian outpatient-clinic. Participants were adults on or at risk of sick leave due to depression and anxiety who were referred for treatment by general practitioners. The crosswalk methodology was applied to estimate the EQ-5D value. Validity was assessed by comparing responses on the EQ-5D with the Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory (BAI), and Subjective Health Complaints (SHC). An ordinal regression model was used to assess known-groups validity. Convergent validity was assessed using Pearson’s correlation coefficient, and a multivariate regression model that included sociodemographic characteristics.

Results: The mean EQ-5D value was 0.631, indicating reduced health status compared to “full health” anchored at 1.0, and patients reported moderate levels of depression and anxiety. Ordinal regression indicated that the EQ-5D could discriminate between different levels of symptom severity for depression and anxiety. The EQ-5D value showed significant correlation with the clinical measures; r=−0.52 for the BDI-II, r=−0.49 for the BAI, and r=−0.44 for SHC. The multivariate regression showed that the clinical variables significantly predicted the EQ-5D value, explaining 40.1% of the variance. Depression and anxiety scores were the largest determinants of EQ-5D value, respectively, whilst sick leave, subjective health complaints, and gender made moderate contributions.

Conclusion: The EQ-5D showed indication of validity in patients on or at risk of sick leave due to depression and anxiety in the present study. The EQ-5D value was sensitive to both symptom severity and functional impairment in the form of sick leave. The findings support the EQ-5D as a feasible and relevant measure of health status in these patients.

Sick leave and return to work for patients with anxiety and depression: a longitudinal study of trajectories before, during and after work-focused treatment

OBJECTIVES

Sick leave due to anxiety and depression is a heterogeneous process constituting a pressing public health issue. This longitudinal study aimed to identify sick leave trajectories among patients before, during and after work-focused treatment, in all 29.5 months. We then aimed to determine the background and clinical characteristics of these trajectory groups.

METHODS

Background and clinical data were collected by patient self-report (N=619) in an observational study in a specialised mental healthcare clinic. Sick leave was recorded from national registry data. A latent growth mixture model identified trajectories. Multinomial logistic regression determined differences in background characteristics while a one-way analysis of variance (ANOVA) identified clinical differences.

RESULTS

We identified three trajectories: The 'Resilient' group (47.7%) had low sick leave throughout the period. The two other groups ('Recovery', 31.8% and 'High risk', 20.5%) had similar pretreatment trajectories: lower sick leave one year prior which increased to high sick leave at the start of treatment. After treatment, the 'Recovery' group made an almost full return to work while the 'High risk' group remained at high sick leave. The two groups with high sick leave had more women and higher age compared with the 'Resilient' group. All groups had similar clinical scores at the start of treatment, but the 'High risk' groups had residual depressive symptoms at the end of treatment. Effect sizes for anxiety and depression were moderate or large for all groups, (Cohen's d=0.74-1.81), and 87.2% of the total sample were fully working one year after treatment.

CONCLUSION

We found three subgroups with distinctly different trajectories. Female gender and higher age were associated with high sick leave at the start of treatment, while residual depressive symptoms at the end of treatment predicted continued sick leave. The study points to the possibility of improving patient outcomes in the future by stratifying and tailoring treatment to patient characteristics.

The Return-to-Work Self-efficacy Questionnaire (RTW-SE): A Validation Study of Predictive Abilities and Cut-off Values for Patients on Sick Leave Due to Anxiety or Depression

Purpose This study aimed to evaluate the validity of the Return-to-Work Self-efficacy Questionnaire (RTW-SE) in a Norwegian sample of patients with common mental disorders. The secondary aim was to provide validated cut-off scores for the RTW-SE. Methods Among patients receiving work-focused therapy (N = 626), the RTW-SE was measured pre-and post-treatment, and work status was assessed up to one-year post-treatment. The factor structure, internal consistency and construct validity were assessed. Furthermore, post-treatment cut-off scores were calculated using receiver operating characteristic (ROC) analysis for patients on sick leave at baseline (n = 314) and at the end of treatment (n = 145). The predictive ability of the suggested RTW-SE cut-off scores were investigated longitudinally. Results Exploratory principal component analysis identified a one-factor solution with high internal consistency (0.91). RTW-SE exhibited small to moderate negative correlations with measures of depression and anxiety, and was significantly different between subgroups of patients with different work status, supporting construct validity. Pre- and post-treatment RTW-SE scores significantly predicted full return to work at 3, 6 and 12 months post-treatment. ROC analysis suggested an upper cut-off score of 4.6, associated with full RTW, and lower cut-off score of 3.7, associated with partial RTW. These cut-offs showed acceptable discriminative ability and significant longitudinal predictive ability. Conclusion The RTW-SE possesses good psychometric properties and the suggested cut-off scores have significant predictive ability in a clinical setting.

Metacognitive Therapy for Work-Related Stress: A Feasibility Study

About 25% of EU workers experience work-related stress for all or most of their working time, showing that work-related stress is a major cause of health problems for the EU population. This situation has been worsened even more by the COVID-19 restrictions embraced by employers worldwide. However, a timely and sustainable intervention protocol for treating such issues has not been developed yet. Thus, the present research shows a first effective attempt based on Metacognitive therapy (MCT) to solve this issue. MCT was practiced on four individuals suffering from chronic work-related stress. Primary outcome variables were general mental health, perceived stress, and blood pressure. Participants were assessed at multiple baselines before the start of therapy and then attended a 3- and 6-months follow-up after treatment termination. Results showed significant improvements in general mental health, perceived stress, and blood pressure in each client. Secondary outcome variables improved too-maladaptive coping strategies, avoidance behaviors, and depression symptoms-corroborating the main findings. At 3- and 6-month follow-up, results were maintained. The findings suggest that MCT might be a promising and sustainable intervention for work-related stress, although a metacognitive model for stress and large-scale RCTs need to be developed and carried out to further explore the effect of MCT on stress. Our results represent one of the first attempts to treat work-related stress via Metacognitive Therapy and support the feasibility of the treatment, both in terms of its efficacy and sustainability, in a historical moment in which work-related stress is increased worldwide because of the COVID-19 pandemic. Within such a realm, our feasibility study should be followed by larger and controlled studies that, if successful, would provide various stakeholders-including organizational and institutional decision-makers-with a solid, timely and cost-effective method to help the workforce coping with work-related stress.

Clinical Characteristics of Patients Seeking Treatment for Common Mental Disorders Presenting With Workplace Bullying Experiences

BACKGROUND

Targets of workplace bullying tend to develop severe mental health complaints, having increased risk of sick leave and expulsion from the workplace. Hence, these individuals are likely to be overrepresented among patients seeking treatment for common mental disorders (CMD). This study investigated the prevalence of exposure to workplace bullying in a patient group seeking treatment for CMD. Further we explored if exposed and non-exposed patients differed on clinical and work-related characteristics.

METHODS

The sample comprised of 675 patients from an outpatient clinic in Norway and consisted of 70% women and had a mean age of 39 (SD = 10.5) years. The study had a cross-sectional design and differences between the patient groups were analysed using chi-square, Mann-Whitney U-tests and independent sample t-tests.

RESULTS

The prevalence of exposure to bullying was 25.8%. The patients exposed to bullying reported significantly more major depressive disorders (MDDs) measured with the MINI psychiatric interview, higher levels of depressive symptoms, anxiety symptoms, subjective health complaints, alcohol use, and lower resilience as measured with questionnaires. Twice as many were on full-time sick leave, reported lower work ability, lower return to work self-efficacy, and lower job satisfaction. A majority preferred another job than the one they have today over returning to their current employment.

CONCLUSION

Victims of workplace bullying are a vulnerable group at risk of expulsion from working life, being overrepresented among patients seeking mental health treatment for CMD. One in four patients represented with such experience have higher levels of psychological symptoms and are more often diagnosed with depression as compared to other patients. Thus, this is a problem that should be addressed in clinical settings. If not addressed there is an increased risk of sick leave and permanent exclusion from working life.