Academic journal article Scandinavian Journal of Work, Environment & Health

Effectiveness of an Exposure-Based Return-to-Work Program for Workers on Sick Leave Due to Common Mental Disorders: A Cluster-Randomized Controlled Trial

Academic journal article Scandinavian Journal of Work, Environment & Health

Effectiveness of an Exposure-Based Return-to-Work Program for Workers on Sick Leave Due to Common Mental Disorders: A Cluster-Randomized Controlled Trial

Article excerpt

Objectives In case of long-term sick leave, gradually increasing workload appears to be an effective component of work-directed interventions to reduce sick leave due to common mental disorders (CMD). CMD are defined as stress-related, adjustment, anxiety, or depressive disorders. We developed an exposure-based return-to-work (RTW-E) intervention and evaluated the effect on time-to-full return to work (RTW) among workers who were on sick leave due to CMD in comparison to those treated with care-as-usual (CAU). CAU is guideline-directed and consists of problem-solving strategies and graded activities.

Methods Using a two-armed cluster-randomized trial, we randomized 56 occupational physicians (OP). Of these, 35 OP treated 160 workers at the start of their sick leave: 75 workers received RTW-E and 85 workers received CAU. These workers were followed over a 12-month follow-up period. The primary outcome measure was time-to-full RTW lasting ≥28 days without recurrence. To evaluate differences between groups, we used intention-to-treat and multilevel Cox's regression analysis.

Results The median time-to-full RTW differed significantly between groups [hazard ratio (HR) 0.55; 95% confidence interval (95% CI) 0.33-0.89]. The workers receiving RTW-E (209 days; 95% CI 62-256) had a prolonged time-to-full RTW compared to workers receiving CAU (153 days; 95% CI 128-178).

Conclusions Workers on sick leave due to CMD treated with RTW-E showed a prolonged time-to-full RTW compared to those treated with CAU. We recommend that OP do not apply RTW-E but continue counseling workers on sick leave due to CMD according to CAU.

Key terms absenteeism; occupational health; sickness absence; RTW.

Common mental disorders (CMD), such as adjustment, anxiety, and depressive disorders are highly prevalent in the working population (1) and are associated with longterm sick leave and a loss of productivity (2). Regular clinical treatments, such as cognitive behavioral therapy or pharmacotherapy, can reduce anxiety and depressive symptoms effectively (3, 4), although the full recovery of work functioning often does not follow automatically (5, 6). Work-directed interventions appear to be a promising means of reducing the time-to-full return to work (RTW) for workers on sick leave due to CMD (7-9), although two studies reported no differences between the intervention and control group (10, 1 1). To understand the results of these two studies, one needs to take into account that both studies used a less intensive but still work-directed intervention as a control group.

We know little about how time-to-full RTW is reduced. We therefore identified three common elements of work-directed interventions in the abovementioned studies: improving the problem-solving skills of workers, restoring contact with the workplace, and gradually increasing the workload. Gradually increasing the workload means gradually increasing the number of working hours and the complexity of the work tasks. Restoring contact with the workplace and gradually increasing the workload are recommended policies for employers when supporting workers in their RTW after long-term sick leave (12). However, a potential disadvantage of gradually increasing the workload for workers on sick leave due to CMD is that work situations that evoke stress or strong emotions can be postponed until the final part of the RTW process. This offers workers who are inclined to avoid these situations the opportunity to be persistent in that avoidant behavior. If emotion-evoking work situations are an intrinsic part of the job that cannot be avoided - eg, a nurse who has become anxious to inject patients - avoidance could easily result in an unnecessary long time-to-full RTW. The findings of van Rhenen et al (13) provide support for the occurrence of avoidance and suggest that the avoidance behavior of workers, in contrast to an active problem-solving style, is associated with an increased frequency and duration of sick leave due to stress-related disorders. …

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