Academic journal article Scandinavian Journal of Work, Environment & Health

Return to Work after Work-Related Stress: A Randomized Controlled Trial of a Work-Focused Cognitive Behavioral Intervention

Academic journal article Scandinavian Journal of Work, Environment & Health

Return to Work after Work-Related Stress: A Randomized Controlled Trial of a Work-Focused Cognitive Behavioral Intervention

Article excerpt

Work-related stress is a major health concern in the 21st century (1), a common cause of sick leave (2, 3) and a substantial source of economic burden (4). Sickness absence may act as a global measure of workers' health that predicts lost productivity and disability pensions (5). Mental health problems are linked to about 45% of all sick leave cases in Denmark (6) at an estimated yearly cost of about €7.5 billion (4). Almost 30% of all sick leave days in Denmark have been estimated to be related to the psychosocial work environment (7), and some evidence suggests that this pattern is also applicable to other European countries (8).

The term "stress" refers to the experience of external demands exceeding personal coping resources, according to the transactional perspective of Lazarus & Folkman (9). Stress may illicit psychological and physiological responses, which, over time, can lead to a variety of stress complaints and impaired functioning (10-12). Work-related stress may merit a unique treatment approach, which not only addresses thoughts and behaviors related to an individual's stress experience, but also the specific conditions at work.

During recent years, Danish departments of occupational medicine have seen a large increase in patients with work-related stress complaints. Many of these patients receive a diagnosis of adjustment disorder or reactions to severe stress [International Classification of Disease (ICD-10)] (13), and the majority are on part- or full-time sick leave. Typical stress complaints include cognitive difficulties, sleep problems, fatigue, tensions, muscular aches and feelings of sadness and anxiousness (14-17). Patients often report difficulties coping with work-related demands like high workload, role ambiguity, or social problems in the workplace.

In meta-analyses, cognitive behavioral therapy (CBT) is more effective at reducing psychological complaints among stressed workers than other stress management interventions (SMI) (3, 18, 19). However, existing literature suffers from problems with sampling biases, lack of hard outcomes, and uncertain generalizability to the target population. For example, the majority of existing studies are based on volunteers from the workplace or stressed workers not on sick leave, and results may therefore not generalize to the broader population. Typically, only psychological measures are used as outcomes (3, 18, 19). Less is known about effective treatments to facilitate return to work (RTW) among patients with clinically significant complaints (3, 18, 19). Only a limited number of randomized controlled trials (RCT) have tested the effect of CBT based interventions for stressed workers on sick leave (10, 20-23).

The strongest effects on RTW have been shown by interventions that combine individual CBT with strategies that specifically target the work environment. For example, studies have combined CBT with a graded approach to RTW and work assignments (20, 21) or with workplace dialogue and mindfulness (23). Group-based CBT reduced self-reported absenteeism in one waitlist controlled study (22); however, other studies have not accelerated RTW by CBT using individual (10, 24) or group formats (10). A Cochrane meta-analysis reported that CBT was not superior to no treatment in reducing length of sick leave among workers with adjustment disorder. However, only nine studies were identified, with even fewer contributing to each meta-analysis (2). Differing results are likely influenced by inconsistencies in selection procedures, small sample sizes, and the lack of thorough diagnostic assessments at baseline to verify whether symptoms may in fact be understood as workrelated. In summary, it remains unclear if CBT-based SMI's speed up RTW in clinical samples with workrelated stress. However, studies that address the workplace in combination with CBT may hold more promise. We tested the efficacy of work-focused CBT combined with an optional workplace intervention for patients on sick leave due to work-related stress complaints, using a three-armed randomized controlled design. …

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