Interventions to improve return to work in depressed people: Cochrane systematic review
Work disability such as sickness absence is common in people with depression.Objectives
To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.Search methods
We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014.Selection criteria
We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and clinical interventions for depressed people that included sickness absence as an outcome.Data collection and analysis
Two authors independently extracted the data and assessed trial quality. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to pool study results in the studies we judged to be sufficiently similar. We used GRADE to rate the quality of the evidence.Main results
We included 23 studies with 26 study arms, involving 5996 participants with either a major depressive disorder or a high level of depressive symptoms. We judged 14 studies to have a high risk of bias and nine to have a low risk of bias.
We identified five work-directed interventions. There was moderate quality evidence that a work-directed intervention added to a clinical intervention reduced sickness absence (SMD -0.40; 95% CI -0.66 to -0.14; 3 studies) compared to a clinical intervention alone.
There was moderate quality evidence based on a single study that enhancing the clinical care in addition to regular work-directed care was not more effective than work-directed care alone (SMD -0.14; 95% CI -0.49 to 0.21).
There was very low quality evidence based on one study that regular care by occupational physicians that was enhanced with an exposure-based return to work program did not reduce sickness absence compared to regular care by occupational physicians (non-significant finding: SMD 0.45; 95% CI -0.00 to 0.91).
Clinical interventions, antidepressant medication
Three studies compared the effectiveness of selective serotonin reuptake inhibitor (SSRI) to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results.
Clinical interventions, psychological
We found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care (SMD -0.23; 95% CI -0.45 to -0.01).
Clinical interventions, psychological combined with antidepressant medication
We found low quality evidence based on two studies that enhanced primary care did not substantially decrease sickness absence in the medium term (4 to 12 months) (SMD -0.02; 95% CI -0.15 to 0.12). A third study found no substantial effect on sickness absence in favour of this intervention in the long term (24 months).
We found high quality evidence, based on one study, that a structured telephone outreach and care management program was more effective in reducing sickness absence than usual care (SMD - 0.21; 95% CI -0.37 to -0.05).
Clinical interventions, exercise
We found low quality evidence based on one study that supervised strength exercise reduced sickness absence compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54). We found moderate quality evidence based on two studies that aerobic exercise was no more effective in reducing sickness absence than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24).Authors' conclusions
We found moderate quality evidence that adding a work-directed intervention to a clinical intervention reduced the number of days on sick leave compared to a clinical intervention alone. We also found moderate quality evidence that enhancing primary or occupational care with cognitive behavioural therapy reduced sick leave compared to the usual care. A structured telephone outreach and care management program that included medication reduced sickness absence compared to usual care. However, enhancing primary care with a quality improvement program did not have a considerable effect on sickness absence. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. More studies are needed on work-directed interventions. Clinical intervention studies should also include work outcomes to increase our knowledge on reducing sickness absence in depressed workers.
Nieuwenhuijsen Karen, Faber Babs, Verbeek Jos H, Neumeyer-Gromen Angela, Hees Hiske L, Verhoeven Arco C, van der Feltz-Cornelis Christina M, Bültmann Ute
Interventions to help depressed people resume work
Depression is a major problem that affects about 300 million people globally. Symptoms of depression include the core symptoms of low mood or loss of interest coupled with other symptoms such as feelings of inadequacy and hopelessness or sleep problems. These symptoms usually impair functioning and therefore sickness absence is common in people with depression. We evaluated the effectiveness of interventions that can help depressed workers to resume work activities.
Studies we found
We found 23 studies, involving 5996 participants, that looked at the effects on sick leave of changes at work that were in addition to regular treatment, better psychological treatment, improving primary care, antidepressant pills and exercise.
Effects of changes at work in addition to regular care
In three studies with 251 participants, researchers looked at changes at work such as work modification or coaching in addition to regular care and found that these reduced sickness absence to a moderate extent.
In two studies, researchers tried to improve care that was already directed at changes at work but did not find any effects of these improvements on sick leave.
Effects of psychological treatment
In three studies with 326 participants, researchers found that cognitive behavioural therapy that was provided online or by telephone reduced sickness absence to a moderate extent compared to regular care.
In one high quality study, a special care programme carried out via the workplace also reduced sick leave when compared to regular care.
Effects of antidepressant pills
Three studies compared antidepressant pills with each other but there were no consistent effects on sickness absence.
Improving primary care
Improving primary care through quality improvement programs for general practitioners did not reduce sickness absence in three studies.
One study found that participants had a reduction in sick leave after doing stretching exercises. Two other studies did not find an effect on sick leave after physical exercises such as running or using the gymnasium.
More studies should look at the effects of changes at work. Regular clinical studies should also measure the effects on sick leave because this is an important consequence of depression.
Implications for practice
We found moderate quality evidence based on three studies that adding a work-directed intervention to a clinical intervention reduces the number of days on sick leave in the medium term when compared to a clinical intervention alone.
There is currently no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another.
We found moderate quality evidence that enhancing primary or occupational care by providing workers with a structured telephone or online cognitive behavioural therapy reduces sickness absence compared to regular care.
We found low quality evidence of no considerable effect for enhanced primary care targeting general practitioners through a quality improvement program.
Based on a single study yielding high quality evidence, we found that a structured telephone outreach and care management program may also lead to reductions in sickness absence of depressed workers.
Implications for research
More research is needed on the addition of work-directed interventions to the clinical care provided. This review shows that such interventions have the potential to reduce sickness absence but the number of studies evaluating these types of interventions is still limited.
More often including occupational outcomes such as sickness absence and work functioning in clinical intervention studies will reveal which clinical interventions can be effective in reducing sickness absence.
To facilitate the synthesis of evidence from various intervention studies, the occupational health field should work towards standardising and validating measures of sickness absence. For future reviews including absenteeism as an outcome measure, it is advisable to report standardised mean differences instead of means as this takes into account the differences in measurement methods.Get full text at The Cochrane Library
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