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Meta-Analysis
. 2020 Oct 13;10(10):CD006237.
doi: 10.1002/14651858.CD006237.pub4.

Interventions to improve return to work in depressed people

Karen Nieuwenhuijsen  1 , Jos H Verbeek  2 , Angela Neumeyer-Gromen  3 , Arco C Verhoeven  4 , Ute Bültmann  5 , Babs Faber  6
Affiliations
Meta-Analysis

Interventions to improve return to work in depressed people

Karen Nieuwenhuijsen et al. Cochrane Database Syst Rev. .

Abstract

Background: 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 April 4th 2020.

Selection criteria: We included randomised controlled trials (RCTs) and cluster-RCTs of work-directed and clinical interventions for depressed people that included days of sickness absence or being off work as an outcome. We also analysed the effects on depression and work functioning.

Data collection and analysis: Two review authors independently extracted the data and rated the certainty of the evidence using GRADE. We used standardised mean differences (SMDs) or risk ratios (RR) with 95% confidence intervals (CI) to pool study results in studies we judged to be sufficiently similar. MAIN RESULTS: In this update, we added 23 new studies. In total, we included 45 studies with 88 study arms, involving 12,109 participants with either a major depressive disorder or a high level of depressive symptoms. Risk of bias The most common types of bias risk were detection bias (27 studies) and attrition bias (22 studies), both for the outcome of sickness absence. Work-directed interventions Work-directed interventions combined with clinical interventions A combination of a work-directed intervention and a clinical intervention probably reduces days of sickness absence within the first year of follow-up (SMD -0.25, 95% CI -0.38 to -0.12; 9 studies; moderate-certainty evidence). This translates back to 0.5 fewer (95% CI -0.7 to -0.2) sick leave days in the past two weeks or 25 fewer days during one year (95% CI -37.5 to -11.8). The intervention does not lead to fewer persons being off work beyond one year follow-up (RR 0.96, 95% CI 0.85 to 1.09; 2 studies, high-certainty evidence). The intervention may reduce depressive symptoms (SMD -0.25, 95% CI -0.49 to -0.01; 8 studies, low-certainty evidence) and probably has a small effect on work functioning (SMD -0.19, 95% CI -0.42 to 0.06; 5 studies, moderate-certainty evidence) within the first year of follow-up. Stand alone work-directed interventions A specific work-directed intervention alone may increase the number of sickness absence days compared with work-directed care as usual (SMD 0.39, 95% CI 0.04 to 0.74; 2 studies, low-certainty evidence) but probably does not lead to more people being off work within the first year of follow-up (RR 0.93, 95% CI 0.77 to 1.11; 1 study, moderate-certainty evidence) or beyond (RR 1.00, 95% CI 0.82 to 1.22; 2 studies, moderate-certainty evidence). There is probably no effect on depressive symptoms (SMD -0.10, 95% -0.30 CI to 0.10; 4 studies, moderate-certainty evidence) within the first year of follow-up and there may be no effect on depressive symptoms beyond that time (SMD 0.18, 95% CI -0.13 to 0.49; 1 study, low-certainty evidence). The intervention may also not lead to better work functioning (SMD -0.32, 95% CI -0.90 to 0.26; 1 study, low-certainty evidence) within the first year of follow-up. Psychological interventions A psychological intervention, either face-to-face, or an E-mental health intervention, with or without professional guidance, may reduce the number of sickness absence days, compared with care as usual (SMD -0.15, 95% CI -0.28 to -0.03; 9 studies, low-certainty evidence). It may also reduce depressive symptoms (SMD -0.30, 95% CI -0.45 to -0.15, 8 studies, low-certainty evidence). We are uncertain whether these psychological interventions improve work ability (SMD -0.15 95% CI -0.46 to 0.57; 1 study; very low-certainty evidence). Psychological intervention combined with antidepressant medication Two studies compared the effect of a psychological intervention combined with antidepressants to antidepressants alone. One study combined psychodynamic therapy with tricyclic antidepressant (TCA) medication and another combined telephone-administered cognitive behavioural therapy (CBT) with a selective serotonin reuptake inhibitor (SSRI). We are uncertain if this intervention reduces the number of sickness absence days (SMD -0.38, 95% CI -0.99 to 0.24; 2 studies, very low-certainty evidence) but found that there may be no effect on depressive symptoms (SMD -0.19, 95% CI -0.50 to 0.12; 2 studies, low-certainty evidence). Antidepressant medication only Three studies compared the effectiveness of SSRI to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Improved care Overall, interventions to improve care did not lead to fewer days of sickness absence, compared to care as usual (SMD -0.05, 95% CI -0.16 to 0.06; 7 studies, moderate-certainty evidence). However, in studies with a low risk of bias, the intervention probably leads to fewer days of sickness absence in the first year of follow-up (SMD -0.20, 95% CI -0.35 to -0.05; 2 studies; moderate-certainty evidence). Improved care probably leads to fewer depressive symptoms (SMD -0.21, 95% CI -0.35 to -0.07; 7 studies, moderate-certainty evidence) but may possibly lead to a decrease in work-functioning (SMD 0.5, 95% CI 0.34 to 0.66; 1 study; moderate-certainty evidence). Exercise Supervised strength exercise may reduce sickness absence, compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54; one study, low-certainty evidence). However, aerobic exercise probably is not more effective than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24; 2 studies, moderate-certainty evidence). Both studies found no differences between the two conditions in depressive symptoms.

Authors' conclusions: A combination of a work-directed intervention and a clinical intervention probably reduces the number of sickness absence days, but at the end of one year or longer follow-up, this does not lead to more people in the intervention group being at work. The intervention may also reduce depressive symptoms and probably increases work functioning more than care as usual. Specific work-directed interventions may not be more effective than usual work-directed care alone. Psychological interventions may reduce the number of sickness absence days, compared with care as usual. Interventions to improve clinical care probably lead to lower sickness absence and lower levels of depression, compared with care as usual. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. Further research is needed to assess which combination of work-directed and clinical interventions works best.

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Conflict of interest statement

Karen Nieuwenhuijsen was an author of one of the included studies: Noordik 2013.

Babs Faber: none known.

Jos Verbeek: none known.

Angela Neumeyer‐Gromen: none known.

Hiske Hees (author on the 2014 update) was an author of one of the included studies: Hees 2013.

Arco Verhoeven: none known.

Christina van der Feltz‐Cornelis (author on the 2008 and 2014 versions) was an author of one of the included studies: Vlasveld 2013. Her employer received an unrestricted grant from Eli Lilly for an investigator‐initiated trial on depression and pain. She also received payment from Benecke for speaking at a symposium on chronic pain. She has received royalties from various publishers on her books on psychiatry.

Ute Bültmann: none known.

None of the authors assessed studies they were authors of for eligibility or risk of bias.

Figures

1
1
PRISMA Study flow diagram of the study selection process until 2014.
2
2
PRISMA Study flow diagram of the study selection process 2014‐2020.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Work‐directed plus clinical versus CAU (medium‐term), Outcome 1: Days of sickness absence
1.2
1.2. Analysis
Comparison 1: Work‐directed plus clinical versus CAU (medium‐term), Outcome 2: Off work
1.3
1.3. Analysis
Comparison 1: Work‐directed plus clinical versus CAU (medium‐term), Outcome 3: Depressive symptoms
1.4
1.4. Analysis
Comparison 1: Work‐directed plus clinical versus CAU (medium‐term), Outcome 4: Work functioning
2.1
2.1. Analysis
Comparison 2: Work‐directed plus clinical versus CAU (long‐term), Outcome 1: Days of sickness absence
2.2
2.2. Analysis
Comparison 2: Work‐directed plus clinical versus CAU (long‐term), Outcome 2: Depressive symptoms
2.3
2.3. Analysis
Comparison 2: Work‐directed plus clinical versus CAU (long‐term), Outcome 3: Work functioning
3.1
3.1. Analysis
Comparison 3: Work‐directed plus clinical versus psychological (medium‐term), Outcome 1: Days of sickness absence
3.2
3.2. Analysis
Comparison 3: Work‐directed plus clinical versus psychological (medium‐term), Outcome 2: Depressive symptoms
3.3
3.3. Analysis
Comparison 3: Work‐directed plus clinical versus psychological (medium‐term), Outcome 3: Work functioning
4.1
4.1. Analysis
Comparison 4: Work‐directed plus clinical versus work‐directed (medium‐term), Outcome 1: Days of sickness absence
4.2
4.2. Analysis
Comparison 4: Work‐directed plus clinical versus work‐directed (medium‐term), Outcome 2: Depressive symptoms
4.3
4.3. Analysis
Comparison 4: Work‐directed plus clinical versus work‐directed (medium‐term), Outcome 3: Work functioning
5.1
5.1. Analysis
Comparison 5: Work‐directed versus CAU (medium‐term), Outcome 1: Days of sickness absence
5.2
5.2. Analysis
Comparison 5: Work‐directed versus CAU (medium‐term), Outcome 2: Off work
5.3
5.3. Analysis
Comparison 5: Work‐directed versus CAU (medium‐term), Outcome 3: Depressive symptoms
5.4
5.4. Analysis
Comparison 5: Work‐directed versus CAU (medium‐term), Outcome 4: Work functioning
6.1
6.1. Analysis
Comparison 6: Work‐directed versus CAU (long‐term), Outcome 1: Off work
6.2
6.2. Analysis
Comparison 6: Work‐directed versus CAU (long‐term), Outcome 2: Depressive symptoms
7.1
7.1. Analysis
Comparison 7: Psychological intervention versus CAU (short‐term), Outcome 1: Days of sickness absence
8.1
8.1. Analysis
Comparison 8: Psychological intervention versus CAU (medium‐term), Outcome 1: Days of sickness absence
8.2
8.2. Analysis
Comparison 8: Psychological intervention versus CAU (medium‐term), Outcome 2: Depressive symptoms
8.3
8.3. Analysis
Comparison 8: Psychological intervention versus CAU (medium‐term), Outcome 3: Work functioning
9.1
9.1. Analysis
Comparison 9: Psychological intervention other psychological (medium‐term), Outcome 1: Days of sickness absence
9.2
9.2. Analysis
Comparison 9: Psychological intervention other psychological (medium‐term), Outcome 2: Off work
9.3
9.3. Analysis
Comparison 9: Psychological intervention other psychological (medium‐term), Outcome 3: Work functioning
9.4
9.4. Analysis
Comparison 9: Psychological intervention other psychological (medium‐term), Outcome 4: Depressive symptoms
10.1
10.1. Analysis
Comparison 10: Psychological intervention versus other psychological (long‐term), Outcome 1: Days of sickness absence
10.2
10.2. Analysis
Comparison 10: Psychological intervention versus other psychological (long‐term), Outcome 2: Off work
10.3
10.3. Analysis
Comparison 10: Psychological intervention versus other psychological (long‐term), Outcome 3: Depressive symptoms
10.4
10.4. Analysis
Comparison 10: Psychological intervention versus other psychological (long‐term), Outcome 4: Work functioning
11.1
11.1. Analysis
Comparison 11: Psychological with antidepressant versus antidepressant (medium‐term), Outcome 1: Days of sickness absence
11.2
11.2. Analysis
Comparison 11: Psychological with antidepressant versus antidepressant (medium‐term), Outcome 2: Depressive symptoms
11.3
11.3. Analysis
Comparison 11: Psychological with antidepressant versus antidepressant (medium‐term), Outcome 3: Work functioning
12.1
12.1. Analysis
Comparison 12: Antidepressant medication versus placebo (medium‐term), Outcome 1: Days of sickness absence
12.2
12.2. Analysis
Comparison 12: Antidepressant medication versus placebo (medium‐term), Outcome 2: Work functioning
13.1
13.1. Analysis
Comparison 13: Antidepressant versus other antidepressant (medium‐term), Outcome 1: Days of sickness absence
13.2
13.2. Analysis
Comparison 13: Antidepressant versus other antidepressant (medium‐term), Outcome 2: Depressive symptoms
13.3
13.3. Analysis
Comparison 13: Antidepressant versus other antidepressant (medium‐term), Outcome 3: Work functioning
14.1
14.1. Analysis
Comparison 14: Improved care versus CAU (medium‐term), Outcome 1: Days of Sickness absence
14.2
14.2. Analysis
Comparison 14: Improved care versus CAU (medium‐term), Outcome 2: Off work
14.3
14.3. Analysis
Comparison 14: Improved care versus CAU (medium‐term), Outcome 3: Depressive symptoms
14.4
14.4. Analysis
Comparison 14: Improved care versus CAU (medium‐term), Outcome 4: Work functioning
15.1
15.1. Analysis
Comparison 15: Improved care versus CAU (long‐term), Outcome 1: Off work
15.2
15.2. Analysis
Comparison 15: Improved care versus CAU (long‐term), Outcome 2: Depressed yes/no
16.1
16.1. Analysis
Comparison 16: Exercise intervention versus CAU or relaxation (medium‐term), Outcome 1: Days of sickness absence
16.2
16.2. Analysis
Comparison 16: Exercise intervention versus CAU or relaxation (medium‐term), Outcome 2: Off work
16.3
16.3. Analysis
Comparison 16: Exercise intervention versus CAU or relaxation (medium‐term), Outcome 3: Depressive symptoms
16.4
16.4. Analysis
Comparison 16: Exercise intervention versus CAU or relaxation (medium‐term), Outcome 4: Work functioning
17.1
17.1. Analysis
Comparison 17: Art therapy versus CAU (medium‐term), Outcome 1: Off work
17.2
17.2. Analysis
Comparison 17: Art therapy versus CAU (medium‐term), Outcome 2: Depressive symptoms
18.1
18.1. Analysis
Comparison 18: Adjunctive diet versus adjunctive social support (medium‐term), Outcome 1: Days of sickness absence
18.2
18.2. Analysis
Comparison 18: Adjunctive diet versus adjunctive social support (medium‐term), Outcome 2: Depressive symptoms
19.1
19.1. Analysis
Comparison 19: Sensitivity analysis: Work directed plus clinical versus CAU (medium‐term), Outcome 1: Days of sickness absence
20.1
20.1. Analysis
Comparison 20: Sensitivity analysis: Psychotherapy versus CAU (medium‐term), Outcome 1: Days of sickness absence
21.1
21.1. Analysis
Comparison 21: Sensitivity analysis: Improved care versus CAU, Outcome 1: Days of sickness absence
22.1
22.1. Analysis
Comparison 22: Sensitivity analysis: Improved care versus CAU cluster, Outcome 1: Days of Sickness absence
See this image and copyright information in PMC

Update of

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Volker 2015 {published data only}
    1. Volker D, Zijlstra-Vlasveld MC, Anema JR, Beekman AT, Brouwers EP, Emons WH, et al. Effectiveness of a blended web-based intervention on return to work for sick-listed employees with common mental disorders: results of a cluster randomized controlled trial. Journal of medical internet research 2015;17(5):e116. [DOI: 10.2196/jmir.4097] - DOI - PMC - PubMed
Wade 2008 {published data only}
    1. Wade AG, Fernandez J, Francois C, Hansen K, Danchenko N, Despiegel N. Escitalopram and duloxetine in major depressive disorder - A pharmacoeconomic comparison using UK cost data. Pharmacoeconomics 2008;26:969-81. - PubMed
Wang 2007 {published data only}
    1. Wang PS, Simon SE, Avorn J, Azocar F, Ludman EJ, McCulloch J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes. JAMA 2007;298(12):1401-11. - PMC - PubMed
Wikberg 2017 {published data only}
    1. Wikberg C, Westman J, Petersson EL, Larsson ME, André M, Eggertsen R, et al. Use of a self-rating scale to monitor depression severity in recurrent GP consultations in primary care - does it really make a difference? A randomised controlled study. BMC Family Practice 2017;18(1):6. [DOI: 10.1186/s12875-016-0578-9] - DOI - PMC - PubMed
Wormgoor 2020 {published data only}
    1. Wormgoor MEA, Indahl A, Andersen E, Egeland J. Effectiveness of briefer coping-focused psychotherapy for common mental complaints on work-participation and mental health: a pragmatic randomized trial with 2-year follow-up. Journal of Occupational Rehabilitation 2020;30(1):22-39. [DOI: ] - PubMed

References to studies excluded from this review

Aasdahl 2017 {published data only}
    1. Aasdahl L, Pape K, Vasseljen O, Johnsen R, Gismervik S, Jensen C, et al. Effects of Inpatient Multicomponent Occupational Rehabilitation versus Less Comprehensive Outpatient Rehabilitation on Somatic and Mental Health: Secondary Outcomes of a Randomized Clinical Trial. Journal of Occupational Rehabilitation 2017;27(3):456-466. [DOI: 10.1007/s10926-016-9679-5] - DOI - PMC - PubMed
Aasdahl 2018 {published data only}
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Aasvik 2017 {published data only}
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Brandes 2011 {published data only}
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Brouwers 2007 {published data only}
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Carlin 2010 {published data only}
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Castillo‐Pérez 2010 {published data only}
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Dalgaard 2014 {published data only}
    1. Dalgaard L, Eskildsen A, Carstensen O, Willert MV, Andersen JH, Glasscock DJ. Changes in self-reported sleep and cognitive failures: a randomized controlled trial of a stress management intervention. Scandinavian Journal of Work, Environment & Health 2014;40(6):569-581. [DOI: 10.5271/sjweh.3460] - DOI - PubMed
Dalgaard 2017 {published data only}
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Dalgaard 2017a {published data only}
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Danielsson 2019 {published data only}
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Dunlop 2011 {published data only}
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Ebert 2014 {published data only}
    1. Ebert DD, Lehr D, Boß L, Riper H, Cuijpers P, Andersson G, et al. Efficacy of an internet-based problem-solving training for teachers: Results of a randomized controlled trial. Scandinavian Journal of Work, Environment & Health 2014;40(6):582-596. [DOI: ] - PubMed
Ebert 2014a {published data only}
    1. Ebert DD, Lehr D, Smit F, Zarski AC, Riper H, Heber E, et al. Efficacy and cost-effectiveness of minimal guided and unguided internet-based mobile supported stress-management in employees with occupational stress: a three-armed randomised controlled trial. BMC Public Health 2014;14:807. [DOI: 10.1186/1471-2458-14-807] - DOI - PMC - PubMed
Eisendrath 2014 {published data only}
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Eklund 2012 {published data only}
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Endicott 2014 {published data only}
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Erkkilä 2011 {published data only}
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Evans 2016 {published data only}
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Finley 2003 {published data only}
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Folke 2012 {published data only}
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Forman 2012 {published data only}
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Fournier 2015 {published data only}
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Furukawa 2012 {published data only}
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Gournay 1995 {published data only}
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Gunnarson 2018 {published data only}
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Hackett 1987 {published data only}
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Han 2015 {published data only}
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Heer 2013 {published data only}
    1. Heer EW de, Dekker J, Van Eck-Sluijs JF van der, Beekman ATF, Marwijk HWJ van, Holwerda TJ, et al. Effectiveness and cost-effectiveness of transmural collaborative care with consultation letter (TCCCL) and duloxetine for major depressive disorder (MDD) and (sub)chronic pain in collaboration with primary care: design of a randomized placebo-controlled muli-Centre trial: TCC: PAINDIP. BMC Psychiatry 2013;13:1-14. - PMC - PubMed
Hirani 2010 {published data only}
    1. Hirani SS, Karmaliani R, McFarlane J, Asad N, Madhani F, Shehzad S. Testing a community derived intervention to promote women's health: preliminary results of a 3-arm randomized controlled trial in Karachi, Pakistan. Southern Online Journal of Nursing Research 2010;10(3):n.a.
Hobart 2019 {published data only}
    1. Hobart M, Zhang P, Weiss C, Meehan S R, Eriksson H. Adjunctive brexpiprazole and functioning in major depressive disorder: a pooled analysis of six randomized studies using the sheehan disability scale. Int J Neuropsychopharmcol 2019;22(3):173-9. - PMC - PubMed
Hollon 2016 {published data only}
    1. Hollon SD, DeRubeis RJ, Fawcett J, Amsterdam JD, Shelton RC, Zajecka J, et al. Notice of Retraction and Replacement. Hollon et al. Effect of cognitive therapy with antidepressant medications vs antidepressants alone on the rate of recovery in major depressive disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71(10):1157-1164. JAMA Psychiatry 2016;73(6):639-640. [DOI: 10.1001/jamapsychiatry.2016.0756] - DOI - PMC - PubMed
Hordern 1964 {published data only}
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Jansson 2015 {published data only}
    1. Jansson I, Gunnarsson AB, Björklund A, Brudin L, Perseius KI. Problem-based self-care groups versus cognitive behavioural therapy for persons on sick leave due to common mental disorders: a randomised controlled study. Journal of Occupational Rehabilitation 2015;25(1):127-140. [DOI: 10.1007/s10926-014-9530-9] - DOI - PubMed
Johansson 2019 {published data only}
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Kennedy 2016 {published data only}
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Kennedy 2019 {published data only}
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Knekt 2011 {published data only}
    1. Knekt P, Lindfors O, Laaksonen MA, Renlund C, Haaramo P, Härkänen, et al. Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up. Journal of Affective Disorders 2011;132:37-47. - PubMed
Knekt 2016 {published data only}
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Kojima 2010 {published data only}
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Kooistra 2014 {published data only}
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Kroenke 2001 {published data only}
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Lagerveld 2012 {published data only}
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Lam 2012 {published data only}
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Lexis 2011 {published data only}
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Löbner 2018 {published data only}
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Maljanen 2016 {published data only}
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Martinez 2011 {published data only}
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Meyer 2009 {published data only}
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Mino 2006 {published data only}
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Morgan 2011 {published data only}
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Mundt 2001 {published data only}
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    1. Oakes TMM, Meyers AL, Marangell LB, Ahl J, Prakash A, Thase ME, Kornstein SG. Assessment of depressive symptoms and functional outcomes in patients with major depressive disorder treated with duloxetine versus placebo. Human Psychopharmacology: Clinical and Experimental 2012;27:47-56. - PubMed
Reavley 2018 {published data only}
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Salminen 2008 {published data only}
    1. Salminen JK, Karlsson H, Hietala J, Kajander J, Aalto S, Markkula J, et al. Short-term psychodynamic psychotherapy and fluoxetine in major depressive disorder: a randomized comparative study. Psychotherapy and Psychosomatics 2008;77:351-7. - PubMed
Saloheimo 2016 {published data only}
    1. Saloheimo HP, Markowitz J, Saloheimo TH, Laitinen JJ, Sundell J, Huttunen MO, et al. Psychotherapy effectiveness for major depression: a randomized trial in a Finnish community. BMC Psychiatry 2016;16:131. [DOI: 10.1186/s12888-016-0838-1] - DOI - PMC - PubMed
Salomonsson 2017 {published data only}
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Sandahl 2011 {published data only}
    1. Sandahl C, Lundberg U, Lindgren A, Rylander G, Herlofsen J, Nygren ÅN. Two forms of group therapy and individual treatment of work-related depression: a one-year follow-up study. International Journal of Group Psychotherapy 2011;61:539-55. - PubMed
Schmitt 2008 {published data only}
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Schoenbaum 2002 {published data only}
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Simon 2000 {published data only}
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References to other published versions of this review

Nieuwenhuijsen 2008
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