Cochrane Corner - Helping employees with depression to return to work sooner
An updated Cochrane Review involving more than 12 000 people on interventions to improve return to work in employees with depression confirms the role of workplace interventions carried out in conjunction with medical treatment.
Content
Authorship
Heike Raatz, Division of Clinical Epidemiology, Universität Basel
Christian Fricke, Suva Versicherungsmedizin
Regina Kunz, Division of Clinical Epidemiology, Universität Basel
Beate Martin, Suva Versicherungsmedizin
The case
Mr. Dürr, a 43-year-old operations manager at a mid-sized business, was involved in a motorcycle accident 12 months ago sustaining a severe spinal fracture accompanied by temporary paraparesis. Following surgery, he suffered from persistent bladder and sexual dysfunction despite extensive rehabilitation measures. Under these circumstances and fearing for his future, he developed depression characterized by social anxiety and disturbed sleep. The depressive symptoms improved during psychiatric and psychotherapeutic treatment with antidepressants and a positive rehabilitation outcome.
Physically, Mr. Dürr now feels able to resume his professional activities. Nonetheless, he becomes anxious about whether he will no longer be able to meet the job requirements. Before the accident, he was responsible for managing 20 employees, supervising machine production and purchasing management. The job places high demands on flexibility, decision-making, and assertiveness, which are still limited in the insuree. Considering the anticipated challenges, his depressive symptoms returned. At his quarterly meeting, the insuree asked his case manager for support, who referred him to the consulting psychiatrist. At his quarterly meeting, the insuree asked his case manager for assistance, who referred him to the consulting psychiatrist. The psychiatrist recalls a recent training course that discussed a Cochrane meta-analysis on measures to facilitate vocational integration of employees with depression [1]. Nine studies involving 1292 employees showed that employees with depression returned to work faster when their employer provided specific work-directed interventions in addition to conventional psychiatric treatment (table). Extrapolated over one year, employees who received both types of support spent 25 fewer days off work. Depressive symptoms subsided quicker (eight studies involving 1025 employees) and the employees felt more resilient at work (five studies, 926 employees). The consultant psychiatrist finds the results of the meta-analysis sufficiently convincing to recommend additional workplace-related measures and approves the cost coverage. The disability insurance office initiates these measures.
Table
Comparison of work‐directed interventions combined with medical interventions versus usual care (period of observation in the studies varies from two months to one year)
|
Outcome |
Number of studies |
Number of participants |
Statistical method for effect size |
Effect size [95% CI] |
Judgement: Robustness of evidence* |
|---|---|---|---|---|---|
|
1. Number of days of sickness absence |
9 |
n = 1292 |
SMD+ |
-0.25 |
Moderately robust |
|
2. Employment status ‘Unfit for Work’ |
2 |
n = 1025 |
Relative risk |
1.08 |
Highly robust |
|
3. Depressive symptoms |
8 |
n = 1-091 |
SMD+ |
-0.25 |
Not very robust |
|
4. Resilience in the workplace |
5 |
n = 926 |
SMD+ |
-0.19 |
Moderately robust |
Key
*For the evaluation of the «robustness of evidence» see annex belowSMD+ = standardised mean difference. We report the difference between the combined intervention «Adjustments in the workplace combined with clinical intervention» and «the usual care» as a standardised mean difference (SMD). The SMD enables results from multiple studies to be brought together into a single meta-analysis. An SMD of –0.2 or 0.2 indicates a slight effect; an SMD of –0.5 or 0.5 indicates a moderate effect; and an SMD of –0.8 or 0.8 indicates a large effect.
Legend
*For the judgement of the «Robustness of Evidence», see annex below. SMD+ = standardized mean difference. We report the difference between the combined intervention «Adjustments in the workplace combined with medical intervention» and «Usual care» as a standardized mean difference (SMD). The SMD enables results from multiple studies to be viewed and analyzed in a single meta-analysis. A SMD of –0.2 or 0.2 indicates a small effect, a SMD of –0.5 or 0.5 indicates a moderate effect, and a SMD of –0.8 or 0.8 indicates a large effect.
The evidence
The Cochrane meta-analysis «Interventions to improve return to work in depressed people» [1]
Objective of the meta-analysis
This review analyses interventions designed to reduce periods of work disability in employees with depression. Employees with depression often experience short-term, medium-term, or even long-term work disability. Helping people to return to work is an important objective for employees, employers and society. Various interventions are available to help to achieve this. The review investigates work-directed integration measures, both with and without medical interventions.
The main objective of work-directed interventions is to reduce the impact of depression on the ability to work. Most of the studies combined multiple individual interventions, such as contact with supervisors, gradual return to work programs, adjusting work requirements or working hours, or learning coping strategies for dealing with depression at work. Medical interventions such as pharmacotherapy, psychotherapy, and physiotherapy in line with guidelines are used to reduce depressive symptoms and thus improve ability to work. These interventions were compared with «the usual care» to answer the following questions:
- How many days were employees with depression on sick leave?
- How many employees with depression were off work (at the end of the study)?
- How serious were people’s symptoms of depression?
- How well could employees with depression cope with their work?
What are the results of the meta-analysis?
We found 45 studies involving 12 109 employees with depression. The studies come from Europe (n=34), the USA (n=8), Australia (n=2), and Canada (n=1). We present the key findings for other comparisons and a post-assessment period up to one year:
Workplace changes combined with a medical program
- are very likely to reduce the number of days on sick leave by an average of 25 days per year (9 studies; 1292 participants) 🙂
- had no effect on the number of employees on sick leave at the end of the study (two studies; 1025 participants) 🙁
- reduce the symptoms of depression (eight studies; 1091 participants)🙂
- may improve ability to cope with work (five studies; 926 participants) 🙂
Workplace changes alone
- may increase the number of days on sick leave (two studies; 130 participants) 😢
- do not reduce the number of people off work at the end of the study (one study; 226 participants) 😐
- probably do not affect symptoms of depression (four studies; 390 participants) 😐
- may not improve the ability to cope with work (one study; 48 participants) 😐
Improved healthcare alone without work-directed interventions (e.g., inclusion in a quality assurance program, care in line with guidelines, or regular phone contact with therapists)
- probably reduces the number of days on sick leave by 20 days (in two well conducted studies involving 692 participants, although not in all seven studies involving 1912 participants) 😐
- probably reduces symptoms of depression (seven studies; 1808 participants) 🙂
- may reduce ability to cope with work (one study; 604 participants) 🙁
Psychotherapy alone without work-direct interventions
- may reduce the number of days on sick leave by 15 days on average (over the course of one year) (nine studies; 1649 participants) 🙂
- may reduce symptoms of depression (eight studies; 1255 participants) 😐
- It remains unclear if psychological therapies alone affect people’s ability to cope with work (one study; 58 participants) 😐
| Legend | |
| 🙂 | Improvement due to the intervention investigated compared to the control intervention |
| 😐 | No definitive difference between the intervention investigated and the control intervention |
| 🙁 | No difference between the intervention investigated and the control intervention |
| 😢 | Exacerbation due to the intervention investigated compared to the control intervention |
Robustness of evidence terminology (Lietz et al. 2020)
The «robustness of evidence» was evaluated by the group of authors.
|
Evaluating the robustness of evidence |
Definition |
|---|---|
|
⊗⊗⊗⊗ Highly robust |
The group of authors is very sure that the real effect is close to the observed effect. |
|
⊗⊗⊗O Moderately robust |
The group of authors is reasonably confident in the observed effect: the real effect is probably close to the observed effect, but it might be substantially different. |
|
⊗⊗OO Not very robust |
The group of authors has limited confidence in the observed effect: there is a high chance that the real effect could differ substantially from the observed effect. |
|
⊗OOO Not robust at all |
The group of authors has very little confidence in the observed effect: the real effect is probably substantially different from the observed effect. |
| Evaluating the robustness of evidence | Definition |
| ⊗⊗⊗⊗ Highly robust | The group of authors is very sure that the real effect is close to the observed effect. |
| ⊗⊗⊗O Moderately robust | The group of authors is reasonably confident in the observed effect: the real effect is probably close to the observed effect, but it might be substantially different. |
| ⊗⊗OO Not very robust | The group of authors has limited confidence in the observed effect: there is a high chance that the real effect could differ substantially from the observed effect. |
| ⊗OOO Not robust at all | The group of authors has very little confidence in the observed effect: the real effect is probably substantially different from the observed effect. |
Correspondence address
Cochrane Insurance Medicine
Division of Clinical Epidemiology
University of Basel
Totengässlein 3
4051 Basel
Bibliography
- Nieuwenhuijsen K, Verbeek JH, Neumeyer-Gromen A, Verhoeven AC, Bültmann U, Faber B. Interventions to improve return to work in depressed people. Cochrane Database of Systematic Reviews 2020, Issue 10. Art. No.: CD006237. DOI: 10.1002/14651858.CD006237.pub4.
- Lietz M, Angelescu K, Markes M, Molnar S, Runkel B, Schell L, et al. GRADE: Von der Evidenz zur Empfehlung oder Entscheidung – Entscheidungen zur Kostenerstattung. Z Evid Fortbild Qual Gesundhwes. 2020;150-152:134-41.