Time is money: general practitioners' reflections on the fee-for-service system

BACKGROUND

Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.

METHODS

We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.

RESULTS

We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.

CONCLUSIONS

GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Effect of Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder on Criminality

OBJECTIVE

Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes.

METHOD

We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference.

RESULTS

Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges.

CONCLUSION

This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning.

STUDY PREREGISTRATION INFORMATION

The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

Risk factors for mortality in patients admitted to a psychiatric acute ward: A prospective cohort study

INTRODUCTION

Associations between psychiatric disorders and mortality have been extensively studied, but limited evidence exists regarding influence of clinical characteristics on mortality risk, at the time of acute psychiatric hospitalization.

METHODS

A prospective total-cohort study included all patients consecutively admitted to Haukeland University Hospital's psychiatric acute ward in Bergen, Norway between 2005 and 2014 (n = 6125). Clinical interviews were conducted at the first admission within the study period, and patients were subsequently followed for up to 15 years in the Norwegian Cause of Death Registry. Competing risks regression models were used to investigate associations between clinical characteristics at first admission and the risk of natural and unnatural death during follow-up.

RESULTS

The mean age at first admission and at time of death was 42.5 and 62.8 years, respectively, and the proportion of women in the sample was 47.2%. A total of 1381 deaths were registered during follow-up, of which 65.5% had natural, 30.4% unnatural, and 4.1% unknown causes. Higher age, male sex, unemployment, cognitive deficits, and physical illness were associated with increased risk of natural death. Male sex, having no partner, physical illness, suicide attempts, and excessive use of alcohol and illicit substances were associated with increased risk of unnatural death.

CONCLUSION

Psychiatric symptoms, except suicide attempts, were unrelated to increased mortality risk. In the endeavor to reduce the increased mortality risk in people with mental disorders, focus should be on addressing modifiable risk factors linked to physical health and excessive use of alcohol and illicit substances.

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification

BACKGROUND

General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.

METHODS

Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach.

RESULTS

Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence.

CONCLUSION

Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study

BACKGROUND

Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS.

METHOD

We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients.

RESULTS

We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work.

CONCLUSIONS

Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

Variation in attitudes toward diagnosis and medication of ADHD: a survey among clinicians in the Norwegian child and adolescent mental health services

Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from "restrictive" to "liberal". We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the "restrictive" end of the spectrum. CFA supported "attitude toward diagnosis" and "attitude toward medication" as separate, and moderately correlated (r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Effect of ADHD medication on risk of injuries: a preference-based instrumental variable analysis

ADHD is associated with an increased risk of injury. Causal evidence for effects of pharmacological treatment on injuries is scarce. We estimated effects of ADHD medication on injuries using variation in provider preference as an instrumental variable (IV). Using Norwegian registry data, we followed 8051 patients who were diagnosed with ADHD aged 5 to 18 between 2009 and 2011 and recorded their ADHD medication and injuries treated in emergency rooms and emergency wards up to 4 years after diagnosis. Persons with ADHD had an increased risk of injuries compared to the general population (RR 1.35; 95% CI: 1.30-1.39), with higher risk in females (RR 1.47; 95% CI: 1.38-1.56) than males (RR 1.23; 95% CI: 1.18-1.28). The between-clinics variation in provider preference for ADHD medication was large and had a considerable impact on patients' treatment status. There was no causal evidence for protective effects of pharmacological treatment on injuries overall for young individuals with ADHD characterized by milder or atypical symptoms. However, there was an apparent effect of pharmacological treatment over time on the risk of injuries treated at emergency wards in this patient group.

Geographical variation in ADHD: do diagnoses reflect symptom levels?

Rates of ADHD diagnosis vary across regions in many countries. However, no prior study has investigated how much within-country geographic variation in ADHD diagnoses is explained by variation in ADHD symptom levels. We examine whether ADHD symptom levels explain variation in ADHD diagnoses among children and adolescents using nationwide survey and register data in Norway. Geographical variation in incidence of ADHD diagnosis was measured using Norwegian registry data from the child and adolescent mental health services for 2011-2016. Geographical variation in ADHD symptom levels in clinics' catchment areas was measured using data from the Norwegian mother, father and child cohort study for 2011-2016 (n = 39,850). Cross-sectional associations between ADHD symptom levels and the incidence of ADHD diagnoses were assessed with fractional response models. Geographical variation in ADHD diagnosis rates is much larger than what can be explained by geographical variation in ADHD symptoms levels. Treatment in the Norwegian child and adolescent mental health services is free, universally available upon referral, and practically without competition from the private sector. Factors beyond health care access and unequal symptom levels seem responsible for the geographical variation in ADHD diagnosis.

Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project

OBJECTIVES

Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency.

METHODS

By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories.

CONCLUSIONS

This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.

The personality profile of IPS employment specialists, and how it relates to job satisfaction: A longitudinal cohort study

The role of the Individual Placement and Support (IPS) employment specialist is a new type of occupation within mental healthcare. High turnover among employment specialists necessitates improvement in their recruitment and retention. One element that impacts retention is job satisfaction. We assessed the personality of 38 employment specialists (Big 5 Inventory-2) and measured job satisfaction over three time periods. Compared to norm data, employment specialists were significantly higher on Extraversion (ΔT = 8.0, CI: 5.59-10.42), Agreeableness (ΔT = 7.8, CI: 5.56-10.12), Conscientiousness (ΔT = 3.3, CI: 0.8-5.84), Open-mindedness (ΔT = 3.5, CI: 0.97-6.07), while lower on Negative emotionality (ΔT = -3.5, CI: -6.5 to -0.42). Extraversion had a substantial longitudinal positive effect on job satisfaction (β at T1 = 0.39; CI: 0.10-0.73) (β at T2 = 0.40; CI: 0.03-0.80), while Negative emotionality - a substantial negative effect (β at T1 = -0.60; CI: -0.90 to -0.30) (β at T2 = -0.50; CI: -0.90 to -0.12). Male gender was significantly associated with higher job satisfaction at the time point 1 (β = -0.46; CI: -0.80 to -0.14). Age, length of employment in the role, Agreeableness, Conscientiousness and Open-mindedness were not found to have substantial significant effects on job satisfaction of employment specialists. Recruiting employment specialists who score high on Extraversion and low on Negative emotionality may be a good fit for the role and job satisfaction.

Impact of Covid-19 Restrictions on Individual Placement and Support Service Delivery in Northern Norway

Individual Placement and Support (IPS) is an evidence-based supported employment program that helps people with severe mental illness to achieve steady, meaningful employment in competitive mainstream jobs. The purpose of this study is to investigate the impact of Covid-19 restrictions on IPS service delivery in Northern Norway between March and October 2020. In Norway, IPS is in the early stages of full-scale implementation and is therefore potentially sensitive to external stressors such as the Covid-19 pandemic. In October 2020 we conducted a retrospective, cross-sectional survey with IPS employment specialists in Northern Norway (n = 25). The purpose was to collect information about how Covid-19 restrictions between March and October 2020 impacted their ability to deliver IPS services. As a result of Covid-19 restrictions, more than half the employment specialists were reassigned to other roles or non-IPS related work tasks. They also reported less collaborative engagement with clinical teams and employers. 69 (20.4%) of IPS users supported by employment specialists gained employment after the Covid-19 restrictions were introduced and 82.8% of unemployed IPS users continued to seek competitive employment despite Covid-19 restrictions. Covid-19 restrictions appear to have created obstacles for IPS service delivery in Northern Norway and have negatively impacted the employment specialists' collaborative engagement with clinical teams. However, IPS employment specialists have shown strong capabilities in overcoming these challenges and services users have remained motivated to seek employment during the pandemic.

Turnover of IPS employment specialists: Rates and predictors

BACKGROUND: There are anecdotal reports of high job turnover of Individual Placement and Support employment specialists. However, no studies have addressed this issue. OBJECTIVE: To explore whether turnover rates among employment specialists are higher compared to public sector employees along with the correlates of turnover intentions. METHODS: A repeated cross-sectional study collected data from 40 employment specialists in Norway using validated scales to measure job perceptions. Turnover intentions were the main outcome. RESULTS: Turnover rate of employment specialists (45.0%) was significantly higher than the average turnover rate of other occupations in the public sector (27.1%) in the same geographical regions (x2 = 6.5, df = 1, p = 0.01). After adjusting for potential confounders, five factors remained significantly and associated with turnover intentions in directions as expected: general job satisfaction (β= –0.33, p <  0.05), satisfaction with current work (β= –0.35, p <  0.05), satisfaction with supervision (β= –0.28, p <  0.05), work meaningfulness (β= –0.42, p <  0.05) and Negative emotionality personality trait (β= 0.58, p <  0.05). CONCLUSIONS: Addressing turnover will positively impact on productivity and job satisfaction of employment specialists along with continuity of employment support for people with mental health conditions.

The field of psychiatry is in crisis. The case for causal modelling in observational data as a supplement to psychiatric epidemiology and clinical trials

Introduction

The field of psychiatry is in a crisis. Developments in pharmacology and psychotherapy, reforms in services, increased spending and reduced treatment-gap have not substantially improved prognosis for patients in psychiatry. Mental disorder remains lethal short-term and disabling long term. In comparison, prognosis has improved dramatically in oncology and cardiology. Controversies in psychiatry are causing variation in clinical practice between hospitals, even within single-provider health systems. There is, for example, variation in rates of ADHD, use of coercive measures, and medication (type of drugs, dose and duration of medication). Current empirical methods are incapable of solving the major controversies in psychiatry. Epidemiology struggles with residual confounding, bias and reverse causality. Randomized controlled trials are expensive and time-consuming. Ethics may also be a barrier for clinical studies investigating variation in clinical practice. From a health management point of view, variation in clinical services within a single-provider system is usually indicative of variation in quality. However, the variability in service delivery caused by these controversies creates a lottery-like situation for the individual patient, who is generally unaware of the crisis in psychiatry, and blinded to the ongoing lottery.

Objectives

We will present a third empirical approach beyond randomized controlled trials and epidemiology which may help solve the crisis.

Methods

A systematic review of preference-based instrument variable analyses.

Results

We identified relevant high quality 185 studies, though almost none in mental health.

Conclusions

Causal modelling in observational data has potential as a third paradigm beyond RCTs and epidemiology, and may help solve the crisis in psychiatry.

Disclosure

No significant relationships.

Economic analyses of supported employment programmes for people with mental health conditions: A systematic review

Background

Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes.

Methods

We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359.

Results

From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes.

Conclusions

There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.

Implementing individual placement and support (IPS): the experiences of employment specialists in the early implementation phase of IPS in Northern Norway. The IPSNOR study

BACKGROUND

For decades there has been a continuous increase in the number of people receiving welfare benefits for being outside the work force due to mental illness. There is sufficient evidence for the efficacy of Individual Placement and Support (IPS) for gaining and maintaining competitive employment. Yet, IPS is still not implemented as routine practice in public community mental health services. Knowledge about implementation challenges as experienced by the practitioners is limited. This study seeks to explore the experiences of the front-line workers, known as employment specialists, in the early implementation phase.

METHODS

Qualitative data were collected through field notes and five focus group interviews. The study participants were 45 IPS employment specialists located at 14 different sites in Northern Norway. Transcripts and field notes were analysed by thematic analyses.

RESULTS

While employment specialists are key to the implementation process, implementing IPS requires more than creating and filling the role of the employment specialist. It requires adjustments in multiple organisations. The new employment specialist then is a pioneer of service development. Some employment specialists found this a difficult challenge, and one that did not correspond to their expectations going into this role. Others appreciated the pioneering role. IPS implementation also challenged the delegation of roles and responsibilities between sectors, and related legal frameworks related to confidentiality and access. The facilitating role of human relationships emphasised the importance of social support which is an important factor in a healthy work environment. Rural areas with long distances and close- knit societies may cause challenges for implementation.

CONCLUSION

The study provides increased understanding on what happens in the early implementation phase of IPS from the employment specialists' perspective. Results from this study can contribute to increased focus on job satisfaction, turnover and recruitment of employment specialists, factors which have previously been shown to influence the success of IPS. The greatest challenge for making "IPS efficacy in trials" become "IPS effectiveness in the real world" is implementation, and this study has highlighted some of the implementation issues.

Preference-based instrumental variables in health research rely on important and underreported assumptions: a systematic review

OBJECTIVE

Preference-based instrumental variables (PP IV) designs can identify causal effects when patients receive treatment due to variation in providers' treatment preference. We offer a systematic review and methodological assessment of PP IV applications in health research.

STUDY DESIGN AND SETTING

We included studies that applied PP IV for evaluation of any treatment in any population in health research (PROSPERO: CRD42020165014). We searched within four databases (Medline, Web of Science, ScienceDirect, SpringerLink) and four journals (including full-text and title and abstract sources) between January 1, 1998, and March 5, 2020. We extracted data on areas of applications and methodology, including assumptions using Swanson and Hernan's (2013) guideline.

RESULTS

We included 185 of 1087 identified studies. The use of PP IV has increased, being predominantly used for treatment effects in cancer, cardiovascular disease, and mental health. The most common PP IV was treatment variation at the facility-level, followed by physician- and regional-level. Only 12 percent of applications report the four main assumptions for PP IV. Selection on treatment may be a potential issue in 46 percent of studies.

CONCLUSION

The assumptions of PP IV are not sufficiently reported in existing work. PP IV-studies should use reporting guidelines.

Causal modelling of variation in clinical practice and long-term outcomes of ADHD using Norwegian registry data: the ADHD controversy project

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is among the most common mental disorders in children and adolescents, and it is a strong risk factor for several adverse psychosocial outcomes over the lifespan. There are large between-country and within-country variations in diagnosis and medication rates. Due to ethical and practical considerations, a few studies have examined the effects of receiving a diagnosis, and there is a lack of research on effects of medication on long-term outcomes.Our project has four aims organised in four work packages: (WP1) To examine the prognosis of ADHD (with and without medication) compared with patients with other psychiatric diagnoses, patients in contact with public sector child and adolescent psychiatric outpatient clinics (without diagnosis) and the general population; (WP2) Examine within-country variation in ADHD diagnoses and medication rates by clinics' catchment area; and(WP3) Identify causal effects of being diagnosed with ADHD and (WP4) ADHD medication on long-term outcomes.

METHOD AND ANALYSIS

Our project links several nationwide Norwegian registries. The patient sample is all persons aged 5-18 years that were in contact with public sector child and adolescent psychiatric outpatient clinics in 2009-2011. Our comparative analysis of prognosis will be based on survival analysis and mixed-effects models. Our analysis of variation will apply mixed-effects models and generalised linear models. We have two identification strategies for the effect of being diagnosed with ADHD and of receiving medication on long-term outcomes. Both strategies rely on using preference-based instrumental variables, which in our project are based on provider preferences for ADHD diagnosis and medication.

ETHICS AND DISSEMINATION

The project is approved by the Regional Ethics Committee, Norway (REC number 2017/2150/REC south-east D). All papers will be published in open-access journals and results will be presented in national and international conferences.

TRIAL REGISTRATION NUMBERS

ISRCTN11573246 and ISRCTN11891971.

Extent of disease at first cancer presentation and previous anxiety and depressive symptoms: the HUNT study

BACKGROUND

Depressive symptoms are associated with higher cancer mortality, whereas anxiety symptoms are associated with lower than expected risk.

AIMS

This study aimed to investigate the prospective association between depressive/anxiety symptoms and the extent of disease (EOD) of first cancer at diagnosis.

METHOD

Prospective population-based study conducted from the second wave of the Nord-Trøndelag Health (HUNT) study. Of 65 000 residents comprehensively interviewed and examined for health status, 407 received first lifetime cancer diagnoses 1-3 years later, ascertained from the Cancer Registry of Norway, and had EOD recorded. Patients with localised disease or regional/distant spread at cancer diagnosis were analysed for earlier depressive/anxiety symptoms ascertained by the Hospital Anxiety and Depression Scale in HUNT.

RESULTS

Beyond-local EOD was present in 59.8% of those with neither anxiety nor depression, in 76.6% of those with depression alone (odds ratio, 2.20; 1.08-4.49), in 39.3% of those with anxiety alone (odds ratio, 0.44; 0.20-0.96) and in 57.7% of those with both anxiety and depression (odds ratio, 0.92; 0.41-2.06). After adjustment for demographic and health status, and cancer type, these associations were marginally stronger, but no longer statistically significant (odds ratios, 2.26; 0.84-6.11; 0.43; 0.15-1.26; and 1.00; 0.98-1.03, respectively).

CONCLUSIONS

In people who develop cancer, beyond-local EOD at diagnosis was more common in people with previous depression and less common in people with previous anxiety; however, independence from confounding factors could not be concluded.

Violence rate dropped during a shift to individualized patient-oriented care in a high security forensic psychiatric ward

BACKGROUND

Contextual variables such as staff characteristics, treatment programs, assessment routines and administrative structures are found to influence patient violence rates in psychiatric forensic wards. The possible effects of current developments in treatment philosophy emphasizing patients' perspective and treatment involvement upon violence rate have not yet been examined. The aim of this paper is to analyse associations between such developments and the occurrence of violent incidents among patients in a high security forensic psychiatric ward.

METHODS

During a 17-year period with stable ward conditions, incidents of violence were systematically collected together with diagnostic, risk assessment and demographic patient characteristics. Changes in care- and organizational related variables such as nursing staff characteristics, treatment and management routines were collected. Multilevel modelling was applied to estimate the relationship between these variables and changes in violent incidents.

RESULTS

A substantial decline in the occurrence of violent incidents paralleled with changes in the ward during the middle phase of the study period. Most of the changes, such as implementation of new treatment and care routines and an increased proportion of female staff and higher education levels, were significantly related to a decrease in the occurrence of violent incidents in the ward.

CONCLUSIONS

Findings in this study suggest that an increase in individualized, patient-oriented care strategies, delivered by well-educated nursing staff with an equally balanced gender distribution contribute to a low level of violence.

Current mental health in women with childhood sexual abuse who had outpatient psychotherapy

Purpose

This study from Norway examines mental health status of women with child sexual abuse (CSA) who formerly had outpatient psychotherapy for anxiety disorders and/or depression. The relative contributions of CSA and other family background risk factors (FBRF) to aspects of mental health status are also explored.

Subjects

At a mean of 5.1 years after outpatient psychotherapy, 56 female outpatients with CSA and 56 without CSA were personally examined by an independent female psychiatrist. Systematic information about current mental health and functioning was collected by structured interview and questionnaires.

Results

Among women with CSA 95% had a mental disorder, 50% had PTSD, and mean global assessment of functioning (GAF) score was 61.8 ± 10.6. In contrast, 70% of women without CSA had a mental disorder, 14% had PTSD, and mean GAF 71.2 + 8.5. GAF and trauma scale scores were mainly determined by CSA, while FBRF mainly influenced the global psychopathology and dissociation scores.

Discussion

We have little knowledge on the mental health status at long-term in women with CSA who had psychotherapy. This study found their mental status to be rather poor, and worse than that of women without CSA who had psychotherapy for the same disorders. From the broad spectrum of mental disorders associated with CSA, this study concerns only women treated as outpatients for anxiety disorders and/or non-psychotic depressions.

Conclusion

Women with CSA showed poor mental health at long-term follow-up after treatment. The fitness of the psychodynamic individual psychotherapy given, or to what extent treatment can remedy the consequences of such childhood adversities, is discussed.

Smoking in relation to anxiety and depression: Evidence from a large population survey: The HUNT study

Smoking is reported to be associated with depression and anxiety. The present study (a) examines these associations taking comorbidity into account, (b) investigates possible confounders, (c) examines how former smokers compared to current and never-smokers in terms of anxiety and depression, and if anxiety and depression decline by time since cessation. Participants (66%) aged 20–89 years in a population-based health survey (N = 60,814) were screened employing the HADS. (a) The association with smoking was strongest in comorbid anxiety depression, followed by anxiety, and only marginal in depression. Associations were stronger in females and younger participants. (b) Variables partly accounting for the association comprised somatic symptoms, socio-demographics, alcohol problems, and low physical activity. (c) Anxiety and depression were most common in current smokers, followed by quitters, and then never-smokers. No decline in anxiety or depression was found with time since cessation. Previous studies of associations between depression and smoking might have overestimated the association when ignoring comorbid anxiety.

Demographic variation in fit note receipt and long-term conditions in south London

Objectives

Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.

Methods

Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.

Results

In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.

Conclusions

For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

A meta-regression of the impact of policy on the efficacy of individual placement and support

OBJECTIVE

Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries.

METHODS

A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank.

RESULTS

The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education.

CONCLUSIONS

The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

Personality and long-term health-related benefits

Background

Although it is well documented that non-medical factors, like educational level, are associated with sick leave and disability pensioning, the role of personality has only been studied to a limited degree.

Aims

To examine how normal personality traits (as measured by 'The Big Five') are associated with long-term sick leave and disability pensioning.

Methods

In 2008, a sample of Norwegian women participating in the population-based Tracking Opportunities and Problems (TOPP) study were assessed for personality traits. Three years later the women reported on their job status and any episodes of sick leave and disability pensioning over the previous 6 months. Using logistic regression analyses, we examined the association between standardized measures of personality traits and any episodes of long-term sick leave and disability pensioning.

Results

Three hundred and sixty-four women were included in the analyses (40% of those invited). One standard level increase in neuroticism was significantly associated with disability pensioning with an odds ratio (OR) of 2.07 (95% confidence interval [CI]: 1.38-3.10). In contrast, an increase in extroversion and conscientiousness was negatively associated with disability pensioning with ORs of 0.59 (0.39-0.90) and 0.65 (0.43-0.99), respectively. For long-term sick leave, there were no significant associations, although the trends in the estimates were similar.

Conclusions

Personality is strongly associated with disability pensioning, but not with long-term sick leave. In particular, high neuroticism, low extroversion and low conscientiousness seem to increase the risk for disability pensioning. Initiatives aimed to reduce the prevalence of disability pensioning should take personality traits into account.

Approaches to implementing individual placement and support in the health and welfare sectors: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and map existing knowledge on the methods and approaches used to implement Individual Placement and Support at scale in the health and welfare sectors, as well as the frameworks and methodological approaches used in implementation studies, and to identify knowledge gaps that are important for further research.

INTRODUCTION

Individual Placement and Support is an evidence-based, standardized approach designed to support people with mental health conditions to gain and maintain competitive jobs in the labor market. Translating scientific knowledge into mainstream practice is challenging, and there is insufficient knowledge of the approaches used to implement Individual Placement and Support at scale in the health and welfare sectors.

INCLUSION CRITERIA

This review will include studies reporting on the implementation of Individual Placement and Support for people with mental health conditions within a health and welfare context, from 1993 to the present. Studies that have abstracts in English, German or Scandinavian languages will be considered. Randomized controlled trials will be excluded.

METHODS

The review will be conducted in accordance with the JBI methodology for scoping reviews. We will follow a three-step search strategy to trace published studies. Search strategies are developed to fit with the databases MEDLINE, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, Base, OpenGrey and CINAHL. Data will be extracted from papers included in the review using data extraction tables developed by the reviewers. A qualitative content analysis will be used to facilitate the mapping of the results.

A comparison of face-to-face and online training in improving managers' confidence to support the mental health of workers

BACKGROUND

In recognition of the important role managers play in the well-being of the staff they supervise, many workplaces are implementing specialised training for leaders to help them better understand and support the mental health needs of their staff. This training can be delivered through face-to-face or online training sessions. Evaluation of such programs have found positive results for each format when compared to a control group, but to date, face-to-face and online manager mental health training have not been compared with one another.

AIMS

This study brings together results from two trials evaluating the same program content, each employing a different mode of content delivery. Both types of training aimed to change managers' confidence to better support the mental health needs of the staff they supervise.

METHODS

Utilising data derived from two previously conducted trials, mean change in manager confidence from baseline at both post-intervention and follow-up were examined for each method of content delivery. An identical way of measuring confidence was used in each study.

RESULTS

Managers' confidence improved from baseline with both methods of training. A greater change was observed with face-to-face training than for online, although both methods had sustained improvement over time. Analyses indicate that at follow-up, improvements in confidence were significant for both face-to-face (t ₁₈  = 5.99; P < .001) and online training (t ₃₉  = 3.85; P < .001). Analyses focused on managers who fully completed either type of training indicated very similar impacts for face-to-face and online training.

CONCLUSIONS

Both face-to-face and online delivery of manager mental health training can significantly improve managers' confidence in supporting the mental health needs of their staff. This change is sustained over various follow-up periods. However, lower retention rates common in online training reduce the relative effect of this method of delivery.

Explaining the gender gap in sickness absence

Background

In many western countries, women have a much higher rate of sickness absence than men. To what degree the gender differences in sickness absence are caused by gender differences in health is largely unknown.

Aims

To assess to what degree the gender gap in sickness absence can be explained by health factors and work- and family-related stressors.

Methods

Norwegian parents participating in the Tracking Opportunities and Problems (TOPP) study were asked about sickness absence and a range of factors possibly contributing to gender differences in sickness absence, including somatic and mental health, sleep problems, job control/demands, work-home conflicts, parent-child conflicts and stressful life events. Using a cross-sectional design, we did linear regression analyses, to assess the relative contribution from health and stressors.

Results

There were 557 study participants. Adjusting for health factors reduced the gender difference in sickness absence by 24%, while adjusting for stressors in the family and at work reduced the difference by 22%. A simultaneous adjustment for health factors and stressors reduced the difference in sickness absence by about 28%.

Conclusions

Despite adjusting for a large number of factors, including both previously well-studied factors (e.g. health, job control/demands) and lesser-studied factors (parent-child conflict and sexual assault), this study found that most of the gender gap in sickness absence remains unexplained. Gender differences in health and stressors account for only part of the differences in sickness absence. Other factors must, therefore, exist outside the domains of health, work and family stressors.

Anxiety, depression and probability of live birth in a cohort of women with self-reported infertility in the HUNT 2 Study and Medical Birth Registry of Norway

OBJECTIVE

The 'psychogenic' hypothesis has a long history in the field of infertility. The present study investigated whether anxiety or depressive symptoms are associated with probability of subsequent live birth in a cohort of infertile women from the general population.

METHODS

Using linked data from 12,987 women in the North-Trøndelag Health Study 1995-97 (HUNT 2) and the Medical Birth Registry of Norway (MBRN) a cohort of 467 women with self-reported infertility was followed prospectively in the MBRN for 11 years with regard to live birth. Anxiety and depressive symptoms were measured at baseline in HUNT 2 by the Hospital Anxiety and Depression Scale (HADS), i.e. the Anxiety (HADS-A) and Depression (HADS-D) sub-scales. The relationship between anxiety or depressive symptoms and live birth in the MBRN was analysed using Cox proportional hazards regression analysis.

RESULTS

Anxiety and depressive symptoms were not associated with live birth rates. For anxiety symptoms, the crude hazard ratios (HR) for live birth was 1.004 (95% confidence interval (CI) = 0.96; 1.05); adjusted HR = 0.99 (95% CI = 0.94; 1.04), for depressive symptoms crude HR was 0.98 (95% CI = 0.92; 1.04); adjusted HR = 1.01 (95% CI = 0.94; 1.08). Among the 104 women with HADS-A ≥ 8 and/or HADS-D ≥ 8, 34 (32.7%) were registered with live birth in MBRN during the period of observation. However, 100 (27.6%) of the 363 women with both HADS-A ≤ 7 and HADS-D ≤ 7 were registered with live birth.

CONCLUSION

Anxiety and depressive symptoms are not associated with probability of live birth in women with self-reported infertility in the general population.

Smartphone application for preventing depression: study protocol for a workplace randomised controlled trial

INTRODUCTION

Depression is the leading cause of life years lost due to disability. Appropriate prevention has the potential to reduce the incidence of new cases of depression, however, traditional prevention approaches face significant scalability issues. Prevention programmes delivered by via smartphone applications provide a potential solution. The workplace is an ideal setting to roll out this form of intervention, particularly among industries that are unlikely to access traditional health initiatives and whose workplace characteristics create accessibility and portability issues. The study aims to evaluate the effectiveness of a smartphone application designed to prevent depression and improve well-being. The effectiveness of the app as a universal, selective and indicated prevention tool will also be evaluated.

METHODS AND ANALYSIS

A multicentre randomised controlled trial, to determine the effectiveness of the intervention compared with an active mood monitoring control in reducing depressive symptoms (primary outcome) and the prevalence of depression at 3 months, with secondary outcomes assessing well-being and work performance. Employees from a range of industries will be invited to participate. Participants with likely current depression at baseline will be excluded. Following baseline assessment, participants, blinded to their allocation, will be randomised to receive one of two versions of the application: headgear (a 30-day mental health intervention) or a control application (mood monitoring for 30 days). Both versions of the app contain a risk calculator to provide a measure of future risk. Analyses will be conducted within an intention-to-treat framework using mixed modelling, with additional analyses conducted to compare the moderating effect of baseline risk level and depression symptom severity on the intervention's effectiveness.

ETHICS AND DISSEMINATION

The current trial has received ethics approval from the University of New South Wales Human Research Ethics Committee (HC17021). Study results will be disseminated through peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000548336; Results.

A New Online Mental Health Training Program for Workplace Managers: Pre-Post Pilot Study Assessing Feasibility, Usability, and Possible Effectiveness

BACKGROUND

Mental health has become the leading cause of sickness absence in high-income countries. Managers can play an important role in establishing mentally healthy workplaces and coordinating their organization's response to a mentally ill worker.

OBJECTIVE

This pilot study aims to evaluate the feasibility, usability, and likely effectiveness of a newly developed online training program for managers called HeadCoach. HeadCoach aims to build managers' confidence in supporting the mental health needs of staff and promote managerial behavior most likely to result in a more mentally healthy workplace.

METHODS

In total, 66 managers from two organizations were invited to participate in this pre-post pilot study of HeadCoach, which was made available to managers to complete at their own pace over a 4-week period. Data were collected at baseline and post intervention via an online research platform. The difference in mean scores for each outcome between these two time points was calculated using paired samples t tests.

RESULTS

Of all the invited managers, 59.1% (39/66) participated in the trial, with complete pre-post data available for 56.4% (22/39) of the participants. The majority of respondents reported positive engagement with the program. During the study period, managers' knowledge regarding their role in managing mental health issues (P=.01) and their confidence in communicating with employees regarding mental illness (P<.001) significantly increased. In addition, a significant increase was observed from the baseline in managers' self-reported actions to use strategies to prevent and decrease stress among their team members (P=.02).

CONCLUSIONS

Although caution is needed due to the absence of a control group, preliminary results of this study suggest that HeadCoach could be a feasible, acceptable, and efficient method of training managers in best workplace practices to help support the mental health needs of their staff.

The role of job strain in understanding midlife common mental disorder: a national birth cohort study

BACKGROUND

Long-standing concerns exist about reverse causation and residual confounding in the prospective association between job strain and risk of future common mental disorders. We aimed to address these concerns through analysis of data collected in the UK National Child Development Study, a large British cohort study.

METHODS

Data from the National Child Development Study (n=6870) were analysed by use of multivariate logistic regression to investigate the prospective association between job strain variables at age 45 years and risk of future common mental disorders at age 50 years, controlling for lifetime psychiatric history and a range of other possible confounding variables across the lifecourse. Population attributable fractions were calculated to estimate the public health effect of job strain on midlife mental health.

FINDINGS

In the final model, adjusted for all measured confounders, high job demands (odds ratio 1·70, 95% CI 1·25-2·32; p=0·0008), low job control (1·89, 1·29-2·77; p=0·0010), and high job strain (2·22, 1·59-3·09; p<0·0001) remained significant independent predictors of future onset of common mental disorder. If causality is assumed, our findings suggest that 14% of new cases of common mental disorder could have been prevented through elimination of high job strain (population attributable fraction 0·14, 0·06-0·20).

INTERPRETATION

High job strain appears to independently affect the risk of future common mental disorders in midlife. These findings suggest that modifiable work-related risk factors might be an important target in efforts to reduce the prevalence of common mental disorders.

FUNDING

iCare Foundation and Mental Health Branch, NSW Health.

A smartphone application for treating depressive symptoms: study protocol for a randomised controlled trial

BACKGROUND

Depression is a commonly occurring disorder linked to diminished role functioning and quality of life. The development of treatments that overcome barriers to accessing treatment remains an important area of clinical research as most people delay or do not receive treatment at an appropriate time. The workplace is an ideal setting to roll-out an intervention, particularly given the substantial psychological benefits associated with remaining in the workforce. Mobile health (mhealth) interventions utilising smartphone applications (apps) offer novel solutions to disseminating evidence based programs, however few apps have undergone rigorous testing. The present study aims to evaluate the effectiveness of a smartphone app designed to treat depressive symptoms in workers.

METHODS

The present study is a multicentre randomised controlled trial (RCT), comparing the effectiveness of the intervention to that of an attention control. The primary outcome measured will be reduced depressive symptoms at 3 months. Secondary outcomes such as wellbeing and work performance will also be measured. Employees from a range of industries will be recruited via a mixture of targeted social media advertising and Industry partners. Participants will be included if they present with likely current depression at baseline. Following baseline assessment (administered within the app), participants will be randomised to receive one of two versions of the Headgear application: 1) Intervention (a 30-day mental health intervention focusing on behavioural activation and mindfulness), or 2) attention control app (mood monitoring for 30 days). Participants will be blinded to their allocation. Analyses will be conducted within an intention to treat framework using mixed modelling.

DISCUSSION

The results of this trial will provide valuable information about the effectiveness of mhealth interventions in the treatment of depressive symptoms in a workplace context.

TRIAL REGISTRATION

The current trial is registered with the Australian and New Zealand Clinical Trials Registry ( ACTRN12617000547347 , Registration date: 19/04/2017).

Systematic review of fit note use for workers in the UK

OBJECTIVES

The fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the 'maybe fit' for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem.

METHODS

Studies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Thirteen papers representing seven studies met inclusion criteria. In the largest study, 'maybe fit' for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. 'Maybe fit' recommendations were made in 8.5%-10% of fit notes received by primary care patients in employment, and in 10%-32% of patients seen by GPs trained in the Diploma in Occupational Medicine. 'Maybe fit' was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the 'maybe fit' option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment.

CONCLUSIONS

Fit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.

Effectiveness of training workplace managers to understand and support the mental health needs of employees: a systematic review and meta-analysis

Managers are in an influential position to make decisions that can impact on the mental health and well-being of their employees. As a result, there is an increasing trend for organisations to provide managers with training in how to reduce work-based mental health risk factors for their employees. A systematic search of the literature was conducted to identify workplace interventions for managers with an emphasis on the mental health of employees reporting directing to them. A meta-analysis was performed to calculate pooled effect sizes using the random effects model for both manager and employee outcomes. Ten controlled trials were identified as relevant for this review. Outcomes evaluating managers' mental health knowledge (standardised mean difference (SMD)=0.73; 95% CI 0.43 to 1.03; p<0.001), non-stigmatising attitudes towards mental health (SMD=0.36; 95% CI 0.18 to 0.53; p<0.001) and improving behaviour in supporting employees experiencing mental health problems (SMD=0.59; 95% CI 0.14 to 1.03; p=0.01) were found to have significant pooled effect sizes favouring the intervention. A significant pooled effect was not found for the small number of studies evaluating psychological symptoms in employees (p=0.28). Our meta-analysis indicates that training managers in workplace mental health can improve their knowledge, attitudes and self-reported behaviour in supporting employees experiencing mental health problems. At present, any findings regarding the impact of manager training on levels of psychological distress among employees remain preliminary as only a very limited amount of research evaluating employee outcomes is available. Our review suggests that in order to understand the effectiveness of manager training on employees, an increase in collection of employee level data is required.

Examination of the double burden hypothesis-a systematic review of work-family conflict and sickness absence

Background: Women consistently have higher sickness absence than men. The double-burden hypothesis suggests this is due to higher work–family burden in women than men. The current study aimed to systematically review prospective studies of work–family conflict and subsequent sickness absence. Methods: A systematic search was conducted in the electronic databases Medline, PsycINFO, and Embase with subject heading terms and keywords with no language or time restrictions. Two reviewers independently screened abstracts and read full-texts with pre-defined inclusion and exclusion criteria. Results: Eight included studies (n = 40 856 respondents) measure perceived work–family conflict and subsequent sickness absence. We found moderate evidence for a positive relationship between work–family conflict and subsequent sickness absence, and that women experience higher levels of work–family conflict than men. Conclusion: Work–family conflict is associated with later sickness absence, and work–family conflict is more common for women than for men. This indicates that work–family conflict may contribute to the gender gap in sick leave. However, further studies are needed to confirm whether this relationship is causal.

A protocol for the HeadCoach trial: the development and evaluation of an online mental health training program for workplace managers

BACKGROUND

Within high income countries, mental health is now the leading cause of long term sickness absence in the workplace. Managers are in a position to make changes and decisions that have a positive effect on the wellbeing of staff, the recovery of employees with mental ill health, and potentially prevent future mental health problems. However, managers report addressing workplace mental health issues as challenging. The aim of the HeadCoach trial is to evaluate the effectiveness of a newly developed online training intervention to determine whether it is able to build managers' confidence to better support individuals within their teams who are experiencing mental ill health, and the confidence to promote manager behaviour likely to result in a more mentally healthy workplace.

METHODS/DESIGN

We will conduct a cluster randomised control trial (RCT) to evaluate the effect of HeadCoach, an online training intervention for managers with a focus on the mental health of their employees, compared to a waitlist control. The target sample is 168 managers, and their direct employees. Managers and employees will be assessed at baseline and at 4-month follow up. Managers will have an additional, intermediate assessment 6-weeks post-baseline. The primary outcome is change from baseline in managers' self-reported confidence when dealing with mental health issues within their team and promoting a mentally healthy workplace. The difference between the intervention and waitlist control groups will be assessed using linear mixed effects repeated measures (MMRM) analysis of variance (ANOVA). Secondary managerial outcomes include mental health literacy, attitudes towards mental health issues in the workplace and managerial behaviour in dealing with mental health matters with their staff. Employee outcomes will be perceived level of manager support, engagement, psychological distress, and rates of sickness absence and presenteeism.

DISCUSSION

To our knowledge this will be the first RCT of a purely online training intervention developed specifically for managers that promotes confidence to both support staff experiencing mental ill health and create a mentally healthy work environment. If successful, this intervention has the potential to provide an effective and efficient method of training managers in workplace mental health and to enhance employee wellbeing.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12617000279325.

Exercise and the Prevention of Depression: Results of the HUNT Cohort Study

OBJECTIVE

The purpose of the present study was to address 1) whether exercise provides protection against new-onset depression and anxiety and 2) if so, the intensity and amount of exercise required to gain protection and, lastly, 3) the mechanisms that underlie any association.

METHOD

A "healthy" cohort of 33,908 adults, selected on the basis of having no symptoms of common mental disorder or limiting physical health conditions, was prospectively followed for 11 years. Validated measures of exercise, depression, anxiety, and a range of potential confounding and mediating factors were collected.

RESULTS

Undertaking regular leisure-time exercise was associated with reduced incidence of future depression but not anxiety. The majority of this protective effect occurred at low levels of exercise and was observed regardless of intensity. After adjustment for confounders, the population attributable fraction suggests that, assuming the relationship is causal, 12% of future cases of depression could have been prevented if all participants had engaged in at least 1 hour of physical activity each week. The social and physical health benefits of exercise explained a small proportion of the protective effect. Previously proposed biological mechanisms, such as alterations in parasympathetic vagal tone, did not appear to have a role in explaining the protection against depression.

CONCLUSIONS

Regular leisure-time exercise of any intensity provides protection against future depression but not anxiety. Relatively modest changes in population levels of exercise may have important public mental health benefits and prevent a substantial number of new cases of depression.

Case-specific colleague guidance for general practitioners' management of sickness absence

Background

General practitioners (GPs) report sickness absence certification as challenging. They express need for support with functional assessment beyond guidelines and reforms. Case-specific collegial one-to-one guidance for other clinical topics has proved popular with GPs and may be an acceptable and effective way to improve GPs skills and competence in sickness absence certification.

Aims

To present a new model of case-specific colleague guidance focusing on the management of long-term sickness absence and to describe its feasibility in terms of application and reception among GPs, and also GPs' self-reports of effects on their practice.

Methods

Randomly selected GPs received case-specific collegial guidance over a 12-month period, in two Norwegian trials, delivered by former GPs employed by the social security administration. We measured reception and perceived effects by GPs' self-report and registered participation and withdrawal rates.

Results

The participation rate (n = 165) was 94%, and no GPs withdrew during training. Among the 116 GPs responding to the survey (70%), 112 (97%; 95% CI 92-99) stated they would recommend it to their colleagues. Considerable benefit from the guidance was reported by 68 (59%; 95% CI 50-68). The GPs self-reported other effects on their sickness absence certification, specifically an increased use of part-time sickness absence (Fit-Note equivalent).

Conclusions

This model of case-specific colleague guidance to aid GPs' management of long-term sickness absence is feasible and was popular. This type of guidance was perceived by GPs to be somewhat beneficial and to alter their sickness absence certification behaviour, though the true impact requires further testing in controlled trials.

Workplace mental health training for managers and its effect on sick leave in employees: a cluster randomised controlled trial

BACKGROUND

Mental illness is one of the most rapidly increasing causes of long-term sickness absence, despite improved rates of detection and development of more effective interventions. However, mental health training for managers might help improve occupational outcomes for people with mental health problems. We aimed to investigate the effect of mental health training on managers' knowledge, attitudes, confidence, and behaviour towards employees with mental health problems, and its effect on employee sickness absence.

METHODS

We did a cluster randomised controlled trial of manager mental health training within a large Australian fire and rescue service, with a 6-month follow-up. Managers (clusters) at the level of duty commander or equivalent were randomly assigned (1:1) using an online random sequence generator to either a 4-h face-to-face RESPECT mental health training programme or a deferred training control group. Researchers, managers, and employees were not masked to the outcome of randomisation. Firefighters and station officers supervised by each manager were included in the study via their anonymised sickness absence records. The primary outcome measure was change in sickness absence among those supervised by each of the managers. We analysed rates of work-related sick leave and standard sick leave seperately, with rate being defined as sickness absence hours divided by the sum of hours of sickness absence and hours of attendance. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613001156774).

FINDINGS

128 managers were recruited between Feb 18, 2014, and May 17, 2014. 46 (71%) of 65 managers allocated to the intervention group received the intervention, and 42 (67%) of 63 managers allocated to the control group were entered in the deferred training group. Managers and their employees were followed up and reassessed at 6 months after randomisation. 25 managers (1233 employees) in the intervention group and 19 managers (733 employees) in the control group provided data for the primary analysis. During the 6-month follow-up, the mean rate of work-related sick leave decreased by 0·28 percentage points (pp) from a pre-training mean of 1·56% (SE 0·23) in the intervention group and increased by 0·28 pp from 0·95% (0·20) in the control group (p=0·049), corresponding to a reduction of 6·45 h per employee per 6 months. The mean percentage of standard sick leave increased by 0·48 pp from 4·97% (0·22) in the intervention group and by 0·31 pp from 5·27% (0·21) in the control group (p=0·169).

INTERPRETATION

A 4-h manager mental health training programme could lead to a significant reduction in work-related sickness absence, with an associated return on investment of £9.98 for each pound spent on such training. Further research is needed to confirm these findings and test their applicability in other work settings.

FUNDING

NSW Health and Employers Mutual Ltd.

A prospective cohort study of depression course, functional disability, and NEET status in help-seeking young adults

PURPOSE

To examine the associations between depression course, functional disability, and Not in Education or Training (NEET) status in a clinical sample of young adults with mental health problems.

METHODS

Young adults aged 15-25 years seeking help from four primary mental health services were invited to participate in a prospective cohort study evaluating the course of psychiatric disorders in youth. Demographic and clinical characteristics, including depressive symptomatology and functioning, were evaluated through clinical interview and self-report at baseline and 12 month follow-up.

RESULTS

A total of 448 young adults participated (70 % female; M: 20.05 years, SD = 2.85). A significant interaction effect for time and depression course was found, such that those who became depressed reported an increase in functional disability and those whose depression remitted reported a significant reduction in functional disability. Developing depression was not a significant predictor of becoming NEET and vice versa: remitted depression did not make a person more likely to reengage in employment or education.

CONCLUSIONS

This is the first study to examine the course of depression, functional disability, and NEET rates among help-seeking young adults. This study confirms the importance of symptom reduction for improved functioning; however, functional disability remained greater than that seen in young people in the community and there was no association between a change in depression and a change in NEET status. These results argue that services need to address functional outcomes and reengagement with education and employment in addition to symptom reduction.

The mental health benefits of employment: Results of a systematic meta-review

OBJECTIVE

The literature on mental health in the workplace largely focuses on the negative impacts of work and how work may contribute to the development of mental disorders. The potential mental health benefits of employment have received less attention.

METHOD

A systematic search of reviews or meta-analyses that consider the benefits of work in regards to mental health was undertaken using academic databases. All relevant reviews were subjected to a quality appraisal.

RESULTS

Eleven reviews were identified as meeting the inclusion criteria, with four deemed to be of at least moderate quality. The available evidence supports the proposition that work can be beneficial for an employee's well-being, particularly if good-quality supervision is present and there are favourable workplace conditions. The benefits of work are most apparent when compared with the well-documented detrimental mental health effects of unemployment.

CONCLUSIONS

The potential positive effects of good work and the role work can play in facilitating recovery from an illness and enhancing mental well-being need to be highlighted and promoted more widely. Future research should aim to further investigate what constitutes a 'good' workplace or a 'good' job in terms of mental health outcomes.

Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence

BACKGROUND

Individual placement and support (IPS) is a vocational rehabilitation programme that was developed in the USA to improve employment outcomes for people with severe mental illness. Its ability to be generalised to other countries and its effectiveness in varying economic conditions remains to be ascertained.

AIMS

To investigate whether IPS is effective across international settings and in different economic conditions.

METHOD

A systematic review and meta-analysis of randomised controlled trials comparing IPS with traditional vocational services was undertaken; 17 studies, as well as 2 follow-up studies, were included. Meta-regressions were carried out to examine whether IPS effectiveness varied according to geographic location, unemployment rates or gross domestic product (GDP) growth.

RESULTS

The overall pooled risk ratio for competitive employment using IPS compared with traditional vocational rehabilitation was 2.40 (95% CI 1.99-2.90). Meta-regressions indicated that neither geographic area nor unemployment rates affected the overall effectiveness of IPS. Even when a country's GDP growth was less than 2% IPS was significantly more effective than traditional vocational training, and its benefits remained evident over 2 years.

CONCLUSIONS

Individual placement and support is an effective intervention across a variety of settings and economic conditions and is more than twice as likely to lead to competitive employment when compared with traditional vocational rehabilitation.

Is infertility really associated with higher levels of mental distress in the female population? Results from the North-Trøndelag Health Study and the Medical Birth Registry of Norway

OBJECTIVE

To explore the effect of ever having tried to conceive for more than 12 months on levels of anxiety and depressive symptoms and to investigate if symptom levels of anxiety and depression in infertile women who remain childless, or go on to have children, respectively, differ from symptom levels in mothers without reports of infertility.

METHODS

Analyses were based on information from 12 584 Norwegian women aged 19-45 years who participated in the North-Trøndelag Health Study from 1995 to 1997 and data from the Medical Birth Registry of Norway. Anxiety and depressive symptoms were measured by the Hospital Anxiety and Depression Scale.

RESULTS

Having tried to conceive for more than 12 months (ever) was weakly associated with higher levels of depressive symptoms. In the categorical analyses, women with resolved infertility had higher levels of anxiety symptoms (B = 0.25 (95% confidence interval (CI) = 0.04-0.47)) and voluntarily childfree had lower levels of depressive symptoms (B = -0.05 (95% CI = -0.50 to -0.21)) than mothers without infertility. However, women with current primary or current secondary infertility had levels of anxiety and depression not significantly different from mothers without infertility.

CONCLUSION

At the population level, and from a longitudinal perspective, unresolved infertility is less burdensome than findings from studies on women seeking help for infertility would suggest.

Associations between delayed completion of high school and educational attainment and symptom levels of anxiety and depression in adulthood

BACKGROUND

There is a higher prevalence of anxiety and depression among adults with lower educational attainment. Delayed completion of high school (HS) is common and represents a potentially complicating factor in the relationship between educational attainment and anxiety and depression. This study aims to investigate whether delayed HS completion is associated with symptom levels of anxiety and depression in adulthood and whether it interacts with later educational attainment in predicting symptom-levels of anxiety and depression in adulthood.

METHODS

The sample consisted of 10 149 participants from the Nord-Trøndelag Health Survey (HUNT 3) between 30 and 46 years of age in 2006. The outcome variables were symptoms of anxiety and depression as measured by the HADS scale. Variables measuring educational attainment were obtained from the National Educational Database in Norway. We used linear regression to estimate associations between educational attainment, delayed HS completion and symptom levels of anxiety and depression in adulthood.

RESULTS

We found delayed HS completion to be associated with higher symptom levels of both anxiety and depression. There was a dose-response association suggesting that each additional year of delay in HS was associated with higher symptom levels for both anxiety and depression. Mean symptom levels of both anxiety and depression were significantly lower among individuals who completed HS within a normative timeframe vs those who were substantially delayed in their HS completion. For anxiety symptoms, we found a statistically significant interaction between delayed HS completion and later educational attainment. This interaction suggested that individuals with a combination of being delayed in HS and having no higher educational attainment had significantly higher levels of anxiety symptoms than all other combinations of later educational attainment and normative/delayed HS completion. For depression, associations between predictors and symptom levels were additive.

CONCLUSIONS

Delayed HS completion is associated with symptom levels of both depression and anxiety and interacts with later educational attainment in predicting symptom levels of anxiety. Individuals with a combination of delayed HS completion and lower educational attainment had particularly high symptom levels of anxiety.